Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of prostate rectal spacer (55874). 
 You asked the Plan to pre-approve insertion of prostate rectal spacer. You say that this item/service is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of this service. 
 
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 insertion of prostate rectal spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee does not meet criteria for coverage of this service. 
Specifically, the records do not show that he has low or favorable Intermediate prostate cancer risk group. The 
records show that he has high risk prostate cancer. Also, the prostate is 82 gm and must be less than 80 gm to 
meet coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of prostate rectal spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve insertion of prostate rectal spacer (55874).
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 services at the inpatient 
rehabilitation facility that cannot be provided at a lower level of care. The Plan denied your request. The Plan 
says the inpatient rehabilitation facility services are 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 enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that without a ventilator the enrollee is at high risk for 
hospital readmission or life-threatening exacerbations. The Plan denied your request. The Plan says the needed 
settings could be delivered by a bilevel positive airway pressure (BiPAP) device. 
 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 ventilator. Our reviewer says that the 
enrollee does not meet criteria for a ventilator. Our physician reviewer found the enrollee may benefit from 
bilevel positive airway pressure (BiPAP) therapy with average volume assured pressure support (AVAPS) 
during sleep as an outpatient. The records do not show this has been tried and failed. Medicare does not cover a 
home ventilator when used in 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 ventilator have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of a ventilator.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for the 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 enrollee is medically stable. At the current functional level, the enrollee needs 
physical and occupational therapy, but does not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. The documentation does 
not support necessity for admission to an IRF. The complexity of the enrollees medical, rehab, and nursing 
needs (combined complexity) does not require acute hospital inpatient rehab stay with an interdisciplinary 
approach to rehabilitative care. The enrollees rehab needs can be safely provided in an alternate and low 
intensity setting such as in an SNF or in-home with services.  
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for code 77001-26 provided on January 12, 2023.

You asked the Plan to pay this claim. The Plan denied your request. Maximus partially overturned the Plans
denial. The Plan requested a reopen and noted that two of the three codes in review were previously paid. The
Plan noted codes 36558 and 76937-26 were paid.

The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers
must report services with the appropriate code. We looked at the file, and Medicare rules. Based on this
information, we decided that Medicare rules for coverage of the services described by procedure code(s)
77001-26 have not been met. In this case, we have confirmed that code 77001 is a column II code to column I
code 77012. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to
pay for the services described by procedure code(s) 77001-26.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoscopic cervical discectomy. 
 
You asked the Plan to pre-approve the procedure. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this procedure is not supported by research and is not covered. 
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the endoscopic cervical discectomy procedure is considered experimental/investigational 
and is not medically necessary for the treatment of neck pain. 
 
 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an endoscopic cervical discectomy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unlimited maintenance aquatic therapy visits. 
 
You asked the Plan to pre-approve unlimited maintenance aquatic therapy visits. 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 unlimited maintenance aquatic therapy 
visits. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found a trial of aquatic therapy can be implemented, and 16 
sessions of therapy should be sufficient to determine if it is improving your level of function and strength. 
Unlimited therapy sessions are not medically necessary and additional therapy sessions can be requested if you are making objective progress with therapy. Unlimited sessions are not appropriate for your medical condition 
and exceed your needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of unlimited maintenance aquatic therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve unlimited maintenance aquatic therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a blood glucose level test (D0412) provided on July 27, 
2023. 
 
You asked the Plan to pay for the blood glucose level test. You say that you are diabetic and your dentist will 
not work on your teeth until they check your blood sugar numbers. 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 July 12, 2023. Therefore, 
we decided that the Plan does not have to pay for a blood glucose level test (D0412) provided on July 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (POC) (E1392). 
 
You asked the Plan to pre-approve a POC. You say that you say that you need a battery operated POC due to 
difficulty breathing while traveling and on airplanes. You say that you get severely fatigued when you leave 
your home and must wait until you get home to use your oxygen concentrator. You also say that this is 
medically necessary. The Plan denied your request. The Plan says the records do not indicate that the enrollee 
is unable to use the portable oxygen tanks provided to meet their needs for portable oxygen. 
 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 a POC. Our reviewer says that the 
requested portable oxygen concentrator (POC) is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the records do not show that you are unable to use portable oxygen tanks to 
meet mobility needs in the home. Medicare does not cover a portable oxygen concentrator for air travel. The 
reviewer also found that there is no documentation that the oxygen concentration (SpO2) can be maintained 
greater than 91% during activity using an oxygen conserving device at a flow rate of 1 to 4 liters per minute 
(L/min). Therefore, the reviewer found that the requested POC 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 a POC have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a portable oxygen concentrator (POC) (E1392).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug 
classes (G0482) provided on April 21, 2023. 
 
You asked the Plan to pay for the definitive UDT for 15-21 drug classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when the criteria in the 
rules section of this letter 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 pay for the definitive UDT for 15-21 drug classes. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found that definitive drug 
testing for only opiates was appropriate and medically reasonable and necessary. The other drug classes were 
not indicated and were not medically reasonable and necessary. Therefore, the definitive UDT for 15-21 drug 
classes was not 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 the definitive UDT for 15-21 drug classes have not been met. Therefore, we 
decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug classes 
(G0482) provided on April 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. The Plan denied your request. The Plan says 
the service is still being studied. 
 
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 genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found genicular artery embolization has not been shown in controlled studies to 
result in sustained long term health benefits in patients with knee pain due to osteoarthritis. 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy and Opdivo. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of Yervoy in combination with 
Opdivo for the treatment of metastatic melanoma after disease progression on this therapy does not meet 
Medicare criteria for safe and effective and otherwise reasonable and necessary for you. The records report that 
you have had disease progression on these drugs. The recommended dosing of these medications in the 
Medicare-approved major drug compendia report that the use is only supported until disease progression or 
unacceptable toxicity. 
 
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 Yervoy and Opdivo.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that an LTACH admission is needed to provide 
the continuation of medically necessary acute care services. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for an LTACH admission. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving with the current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for transfer. There are no service at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it 
would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prosthesis additions identified with codes L5828,
L5845, L5850, L5925, L5981, and L5986 for the enrollee.

You asked the Plan to pre-approve prosthesis additions identified with codes L5828, L5845, L5850, L5925,
L5981, and L5986. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan
says that the requested items are not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for prosthesis
additions identified with codes L5828, L5845, L5850, L5925, L5981, and L5986. Our Medical Director states
that the enrollee underwent a right above-knee amputation due to peripheral vascular disease. His medical
history includes coronary artery disease, CABG, heart failure, and diabetes. The Limb Loss Clinic note dated
February 9, 2023, documents that the enrollee's functional level was then K2. Our Medical Director found that
the enrollee's condition does not meet criteria for coverage of prosthesis additions identified with codes L5828,
L5845, L5850, L5925, L5981, and L5986.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of prosthesis additions identified with codes L5828, L5845, L5850, L5925, L5981,
and L5986 have not been met. Therefore, we decided that the Plan does not have to pre-approve prosthesis
additions identified with codes L5828, L5845, L5850, L5925, L5981, and L5986 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sprint PNS (64555). 
 
You asked the Plan to pre-approve Sprint PNS. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says the device has not been shown to be effective in the medical literature. 
 
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 Sprint PNS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this is considered experimental therapy for knee pain from osteoarthritis. Therefore, the 
request is deemed not medically reasonable and 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 Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Sprint PNS (64555).