Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires minimal to moderate assistance 
with transfers still, and ADLs and gait training. The enrollee could tolerate 3 
hours of therapies before returning home. Physical and occupational therapy in an IPR setting would assist the 
enrollee with multiple comorbidities. The Plan denied your request. The Plan says the inpatient rehabilitation 
facility (IRF) services you are requesting do not meet the requirements for approval.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 performed on May 23, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) 95937 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95937 is "Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report documents 
train of four testing. For CPT 95937, the provider performs neuromuscular junction testing by repetitive stimulation of a nerve supplying a muscle to diagnose a patient with a known or suspected disorder of the 
neuromuscular junction.  It is not appropriate to bill separately for train-of-four (TOF) monitoring. CPT 95937 
is not appropriate for train of four testing. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95937 performed on May 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says your request is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive rehabilitation physician or nursing oversight in an IRF. The enrollee's 
functional level does not require treatment by multiple therapies including physical or occupational therapy in 
an intensive rehabilitation program in an IRF. While the enrollee may be able to participate in therapies, the 
documentation does not support that they require this on an intensive level in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria. The Plan denied your request. The Plan says that the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee is currently stable enough to transfer from the short-term acute care hospital. 
The enrollee's medical condition and care requirements cannot be adequately addressed in a lower level of care. 
Therefore, the criteria for coverage have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have been met. Therefore, we decided that the Plan has to 
pre-approve LTACH services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are having difficulty walking without assistance. 
The Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs can be provided in 
a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can be provided at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ablation, irreversible electroporation; 1 or more tumors 
per organ, including imaging guidance, when performed, percutaneous (0600T). 
 
You asked the Plan to pre-approve ablation, irreversible electroporation. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve ablation, irreversible electroporation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found NanoKnife (irreversible electroporation) is not medically reasonable 
and necessary in this case. Irreversible electroporation (IRE) including use of the NanoKnife for tissue ablation 
is considered experimental and investigational for treatment of prostate cancer due to insufficient evidence in 
the peer-reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ablation, irreversible electroporation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ablation, irreversible electroporation; 1 or more tumors per organ, 
including imaging guidance, when performed, percutaneous (0600T).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
Plan's required drugs, Remicade, Inflectra, or Infliximab and Stelara. The records do not show that the required 
drugs would be contraindicated or less effective; therefore, Ilumya is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ilumya.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additions to the lower prosthesis identified with codes 
L5856, L5858, L5845, L5848, L5850, L5981, and L5968. 
 
You asked the Plan to pre-approve additions to the lower prosthesis identified with codes L5856, L5858, 
L5845, L5848, L5850, L5981, and L5968. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that prosthesis additions are only covered for certain 
indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additions to the lower prosthesis 
identified with codes L5856, L5858, L5845, L5848, L5850, L5981, and L5968. Our reviewer says that the 
documentation does not support that the requested additions are medically reasonable or necessary. Our 
physician reviewer found the enrollee received the current prosthetic knee and foot in April 2022. The 
physician documentation does not support that the enrollee is a K3 ambulator. The enrollee's use of an assistive 
device even prior to amputation and current walker/wheelchair use with K3 knee and foot, fall history with K3 
components, documentation of significant medical conditions including cardiac issues preventing participation 
in physical therapy, and medical history including dyspnea on exertion do not support the enrollee is at a K3 
activity level. Therefore, the enrollee does not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additions to the lower prosthesis identified with codes L5856, L5858, L5845, 
L5848, L5850, L5981, and L5968 have not been met. Therefore, we decided that the Plan does not have to pre-approve additions to the lower prosthesis identified with codes L5856, L5858, L5845, L5848, L5850, L5981, 
and L5968.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the stimulator. Our reviewer says that 
the requested stimulator is not medically reasonable or necessary. Our physician reviewer found that there is no 
documentation of non-union and 9 months has not passed since surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an osteogenesis stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that you need the dentures replaced. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 20, 2022. Therefore, 
we decided that the Plan does not have to pre-approve an upper partial denture (D5213).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were independent before going into the hospital 
and would like to return to being independent. The Plan denied your request. The Plan says you do not meet the 
criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on March 1, 2023, billed with 
codes 87798, 87801, 87481 and 87150. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you have billed the services at issue correctly. The Plan denied your request. The Plan says panel testing should be billed using one HCPCS/CPT code on the claim.
 
The Plan must follow Medicare rules. The rules say that if a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. This was a panel test that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on March 1, 2023, billed with codes 87798, 87801, 87481 and 87150.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an upgraded electronic connection (E2311) and
a residual limb support (E1020).

You asked the Plan to provide coverage for an upgraded electronic connection (E2311) and a residual limb
support (E1020). The Plan denied your request. The Plan says Medicare coverage criteria are no met. Maximus
overturned the denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an upgraded
electronic connection (E2311) and a residual limb support (E1020). The medical records show you are a 19-
year-old man with a medical history that includes a T10 myelomeningocele, hydrocephalus with shunt
placement, neurogenic bladder, diabetes, and spiral fracture of left femur. You have 0/5 strength in his lower
extremities, and 4-/5 strength in the bilateral upper extremities. The Plan is correct in this case. Given your
upper extremity strength, the clinical documentation does not support that an upgraded electronic connection is
medically reasonable and necessary. In addition, the clinical documentation does not support the need for a
residual limb support.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage an upgraded electronic connection (E2311) and a residual limb support (E1020).
Therefore, we decided that the Plan does not have to provide coverage for an upgraded electronic connection
(E2311) and a residual limb support (E1020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7140) for tooth #2, #6, #7, #8, #9, #10, #11, 
#15, #18, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30, the alveoloplasty (D7310) on all 4 
quadrants, and the deep sedation (D9222 and D9223) provided on July 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental procedures should be a medical claim 
because you needed the extractions after your radiation treatments. The Plan denied your request. The Plan 
says the denial of authorization for these services is correct, because the extractions, the alveoloplasty, and the 
deep sedation are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The requested extractions, the alveoloplasty, and the deep sedation in dispute meets the Medicare definition of 
dental, since it is a service which involved the care and treatment of teeth or structures directly supporting the 
teeth. The extractions, the alveoloplasty, and the deep sedation does not fall under any of Medicare exceptions 
for coverage of non-routine dental care. Though the Plan offers a dental benefit in excess of Medicare 
coverage, the requested items or services are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for an extraction (D7140) for tooth #2, #6, #7, #8, #9, #10, #11, #15, 
#18, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30, the alveoloplasty (D7310) on all 4 quadrants, 
and the deep sedation (D9222 and D9223) provided on July 19, 2022.