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's current medical condition requires an 
IRF admission. The Plan denied your request. The Plan says the enrollee's condition does not meet the 
requirements for an IRF admission.  
 
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 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. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for behavioral health services provided on February 11, 2023, to 
February 20, 2023. 
 
You asked the Plan to pay for behavioral health services. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says it 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 pay for behavioral health services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not meet the criteria for treatment in an acute inpatient mental 
health treatment beyond the date in question of February 16, 2023 forward and could have been treated in a 
lesser restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant 
while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of behavioral health services have not been met. Therefore, we decided that the 
Plan does not have to pay for behavioral health services provided on February 11, 2023, to February 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reverse total shoulder arthroplasty (23472). 
 
You asked the Plan to pre-approve reverse total shoulder arthroplasty. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 reverse total shoulder arthroplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested reverse total 
shoulder arthroplasty is not medically reasonable or 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 reverse total shoulder arthroplasty have not been met. Therefore, we decided 
that the Plan does not have to pre-approve reverse total shoulder arthroplasty (23472).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Percutaneous Left Atrial Appendage Closure (LAAC) 
device. 
 
You asked the Plan to pre-approve the LAAC device. You say that you have been dealing with requesting 
surgical authorization since October 25th, and the situation is now urgent. You say that the enrollee is 
scheduled for surgery on December 12th. The Plan denied your request. The Plan says the records show you do 
not have documentation of a formal shared decision-making interaction with an independent non-interventional 
physician using an evidence-based decision tool on oral anticoagulation prior to the LAAC. 
 
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 the LAAC device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is elevated risk of thromboembolic stroke due to atrial fibrillation and an 
elevated CHADS2VASC score. The enrollee expresses concern about bleeding from the gastrointestinal (GI) 
tract or from falling due to ankle problems. While there is reference to consideration of the LAAC, there is no 
documentation of performance of an evidence-based shared decision-making interaction on anticoagulation. As 
such, guidelines would not support implantation of a LAAC in this setting. LAAC placement would not be 
considered reasonable or medically necessary in this enrollees clinical management. 
 
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 LAAC device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Percutaneous Left Atrial Appendage Closure (LAAC) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 94060 and 94726 billed for date of service 
August 30, 2022. 
 
You asked the Plan to pay for procedure code(s) 94060 and 94726. You say that the claim is billed correctly 
and should be paid. The Plan denied your request. The Plan says this code is included in the facility payment 
and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 94060 and 94726. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 94060 and 
94726. Based on this information, we decided that Medicare rules for coverage of procedure code 94060 and 
94726 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
94060 and 94726 billed for date of service August 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 13, 2022, 
to September 16, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that I21.A1 
is supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says the secondary diagnosis at issue was not supported. As such, the DRG was 
correctly reduced.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code I21.A1, defined as 
myocardial infarction type 2. 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 pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that the reported diagnosis code I21.A1 is not 
supported.  Our physician reviewer found the enrollee presented following a suspected seizure. Laboratory 
studies showed mildly elevated troponins, which were attributed to hypertension. The enrollee did not have 
chest pain or electrocardiographic changes. While the enrollee had evidence of demand ischemia, there is no 
evidence that the enrollee had an infarction. As such, the billing of I21.A1 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 13, 2022, to September 16, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (62323). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when certain requirements are met. 
 
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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
does not reveal a clear history and objective physical examination and concordant radiological image-based 
diagnostic testing that supports that you have lumbar radiculopathy, radicular pain and/or neurogenic 
claudication due to disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, 
producing foraminal or central spinal stenosis, or post-laminectomy syndrome, acute herpes zoster associated 
pain. The documentation does not reveal that there is radiculopathy, radicular pain and/or neurogenic 
claudication severe enough to greatly impact quality of life or function. An objective pain scale or functional 
assessment must be performed at baseline (prior to interventions). The documentation does not reveal that you 
have had a failure to respond to four (4) weeks of noninvasive conservative care such as physical therapy. The 
documentation does not reveal the quantity of prior epidural steroid injections, details of the approach and 
specific level of the injections with objective evidence of at least 50% of sustained improvement in pain relief 
and/or improvement in function measured from baseline using SAME scale for at least three months or after 14 
days can be performed using a different approach, level and/or medication, if appropriate, with the rationale 
and medical necessity for the second ESI documented in the medical record. The documentation is not clear 
that you are participating in an active rehabilitation program, home exercise program or functional restoration 
program. The criteria have not 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (62323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the records provided support the need for 
the device in dispute. The Plan denied your request. The Plan says a home ventilator is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 a home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. The enrollee has severe COPD with a Forced Expiratory Volume in One Second (FEV1) 
of 32% of predicted. The enrollee has had multiple hospitalizations for exacerbations of COPD. However, the 
record does not include an arterial blood gas documenting carbon dioxide (CO2) retention. There is a venous 
blood gas from September 19, 2023, with a PvCO2 of 51. The enrollee has had a home ventilator in the past 
but reportedly did not tolerate it. At the most recent outpatient visit on November 13, 2023, the enrollee stated 
she tolerated and felt benefit from the home ventilator. There is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. If the enrollee does have chronic CO2 retention, they may benefit from BiPAP with 
average volume assured pressure support (AVAPS) during sleep as an outpatient. The records do not show this 
has been tried and failed as an outpatient. Medicare does not cover a home ventilator when used at settings that 
can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drive wheel color insert with adhesive tape (K0108 x2). 
 
You asked the Plan to pre-approve drive wheel color insert with adhesive tape. You say that the items are 
necessary. The Plan denied your request. The Plan says the requested items are not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve drive wheel color insert with adhesive tape (K0108 x2).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nourianz. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nourianz.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for long term acute care hospital (LTACH)
services for the enrollee.

You asked the Plan to provide coverage for the LTACH services. You say that at the time of the appeal,
transfer to an LTACH was medically necessary for the enrollee. The Plan denied your request. The Plan says
the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the correct criteria. The Plan noted that The Maximus reviewer
did not consider that the medical records show the enrollee's physician described him as stable and appropriate
for transfer home or to a skilled nursing facility as his care in an acute hospital setting was complete.

The Plan is correct in this case. 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. LTACH facilities are certified as acute care hospitals, and in general, do not provide clinical services
that are materially different than those of short-term acute care hospitals.

The available clinical documentation does not support that this enrollee required services at an LTACH. The
medical records show the enrollee's hospital course was completed. The enrollee's physician indicated the
enrollee's wound care and intra-venous antibiotics could be provided at a lower level of care. Medicare rules
for coverage of transfer to an LTACH were not met. Therefore, we decided that the Plan does not have to
provide coverage for long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has no documented trial or 
failure of bilevel positive airway pressure (BIPAP) therapy. The arterial blood gas analysis (ABG) 
shows compensated acidosis and given degree of severity of chronic obstructive pulmonary disease (COPD), 
BIPAP would be best practice starting point for this enrollee. The documentation does not support need or 
initiation of home ventilator at this time.  Hence, no home ventilator is indicated per documentation provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.

You asked the Plan to pre-approve SNF care. You say that at the time of the appeal, SNF admission was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan stated that Maximus did not apply the correct criteria. The Plan
referenced the medical records that show the enrollee had a continued restriction of non-weightbearing on the
right leg for at least an additional 12 days and had reached independence for wheelchair mobility. At the time
of the admission request, this care would have been custodial in nature, which is not covered by Medicare.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care
in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
Based on the medical records provided, the enrollees did not require skilled therapy or skilled nursing services
on a daily basis at an inpatient level of care. Medicare rules for coverage of SNF care were not met at the time
of the appeal. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF)
care for the enrollee.