Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve CALR and MPL gene tests. 
 
You asked the Plan to pre-approve CALR and MPL. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that genetic tests for BCR-ABL negative 
myeloproliferative disease may be covered if certain conditions 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 CALR and MPL. Our reviewer says 
that the enrollee meets criteria for these gene tests. Our physician reviewer found the enrollee has been a daily 
smoker for 45 years. In November 2023 the enrollee's hemoglobin was 18.0. The assessment was that the 
elevated red blood cell count was likely due to history of smoking but wanted to rule out polycythemia vera. A 
JAK2 V617F was obtained and found to be negative for a mutation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CALR and MPL have been met. Therefore, we decided that the Plan has to pre-
approve CALR and MPL gene tests.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's continued care needs include oxygen 
weaning, tracheostomy care, and therapy to get stronger. The Plan says there is no indication that it will take an 
average of 3 weeks for continued oxygen weaning from the current 10 liters. The Plan says the enrollee can 
receive this care in another setting. 
 
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 not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee can eat and is in the process of weaning down the oxygen requirements 
and is not expected to require 25 days to do this  
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 not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet criteria.  
 
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 surgical repair of malunion of an ankle fracture. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt/recline, legrests, seat elevator) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
enrollee meets the criteria for the requested power wheelchair and components. The Plan denied your request. 
The Plan says the notes do not show a medical need for the requested multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain criteria 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 a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found the provided documentation indicates that the 
enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. 
Therefore, the reviewer found that the requested Group 3 power wheelchair with multiple power options 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 Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options (tilt/recline, legrests, seat elevator) and accessories.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiology services described by code 73560-26 performed on date 
of service October 3, 2022. 
 
You asked the Plan to pay for 73560-26. You say that 73560-26 should be paid as billed because it was coded 
correctly and is supported in the medical record. The Plan denied your request. The Plan says that 73560-26 is 
denied because the total procedure for this code was already billed for this date of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan's rationale is that 73560-26 is denied because the total 
procedure for this code was already billed for the date of service in question, October 3, 2022. The Plan has not 
provided any evidence that the total procedure (including both professional and technical components) of code 
73560 was billed by any provider on the date in question. The Plan does not appear to have requested 
information to support that this service may have been performed multiple times. As such, the Plan has not 
substantiated their denial in this case. Therefore, we decided that the Plan has to pay for the radiology services 
described by code 73560-26 performed on date of service October 3, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that the enrollee would benefit from this CGM. The Plan 
denied your request. The Plan says the medical criteria for a CGM has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 3 continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visits (99214, 99213) and 
ultrasound (93971), provided on November 11, 2022, and December 2, 2022. 
 
You asked the Plan to waive the copayment for the office visits and ultrasound. You say that the cost share is 
wrong. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $55 
copayment for Medicare- covered radiological diagnostic services for outpatient diagnostic tests and 
therapeutic services and a $10 copayment for specialist physician services.  
 
You have been asked to pay a $55 copayment for Medicare- covered radiological diagnostic services for the ultrasound and a $10 copayment for each specialist office visits. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the office visits (99214, 99213) and ultrasound (93971), provided on November 11, 2022, and 
December 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower
denture (D5120) for the enrollee.

You asked the Plan to pre-approve a complete upper denture and a complete lower denture. You say that you
are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that this is not
covered by the enrollee's Plan. Maximus overturned the Plan's denial because of a lack of information. The
Plan requested a reopening and stated that this is not covered by the enrollee's Medicare benefit. The Plan is
correct in this case. The Plan provided the 2023 Dental Benefit Details document which lists all the covered
services. Complete upper and lower dentures are not listed in the document and therefore not a covered service.
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a
complete lower denture (D5120) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom abutment (D6057) and retainer (D6068) for 
dental implants. 
 
You asked the Plan to pre-approve a custom abutment and retainer. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are not a 
covered benefit. 
 
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
custom abutment (D6057) and retainer (D6068) for dental implants.
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 has fallen and had surgery still needing 
inpatient rehabilitation and still requiring physical and occupational therapy to return home. The Plan denied 
your request. The Plan says the enrollee's condition does not meet all the requirements for inpatient 
rehabilitation admission. The Plan says services may be provided at a lower level of care.  
 
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 medical 
records support 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. It is not a 
reasonable expectation that the 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 27245 billed for date of service December 2,
2022.

You asked the Plan to pay for procedure code 27245. You say that you submitted medical records for review.
The Plan denied your request. The Plan says that code 27245 remains not supported. Maximus overturned the
Plan's denial. The Plan requested a reopening and stated that this was billed with the incorrect date of service.
The Plan is correct in this case. The claim shows you billed this service for December 2, 2022, however the
records submitted show this service was performed on December 3, 2022. The claim form was submitted with
the incorrect date of service. Therefore, we decided that the Plan does not have to pay for procedure code
27245 billed for date of service December 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of bone of eye 
socket, face, and/or neck. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary for the enrollee's 
medical problems they are having with tinnitus, dizziness and giddiness. The Plan denied your request. The 
Plan says the enrollee does not meet the criteria for the requested scan. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 the MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found the provided records indicate an MRI of the 
brain is needed for evaluation of the enrollees symptoms. The provided records do not indicate medical 
necessity for the requested MRI. Additional records indicate the MRI of the orbit, face, and neck without 
contrast was ordered in error. 
 
 
 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of bone of eye socket, face, and/or neck.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that the downgraded codes are not accurate. The 
Plan denied your request. The Plan says the enrollee's annual maximum allowance amount 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 annual allowance amount was exhausted on date of service January 31, 2023. Therefore, we 
decided that the Plan does not have to pay for dental services over the allowed annual dental allowance amount 
provided on January 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a replacement cushion (E2619), support pads
(K0108 x2), mesh covers for pads (K0108 x2), thigh/hip supports (K0108 x2), stealth gel pads, and wide
footplates (K0108 x2) for the enrollee.

You asked the Plan to provide coverage for these accessories. You say that the denied accessories were
medically necessary. The Plan denied your request. The Plan says the denied accessories were convenience
items and/or were not coded correctly. Maximus overturned the Plans decision. The Plan requested a reopen
and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare only covers equipment that
services a direct medical purpose. Medicare rules say that providers must report services correctly. In this case,
the replacement cushion was ordered in error as a replacement cushion was already approved within the other
codes listed. The support pads, mesh covers for pads, thigh/hip supports, stealth gel pads and wide foot plates
are convenience items and do not serve a medical purpose. Therefore, we decided that the Plan does not have to
provide coverage for a replacement cushion (E2619), support pads (K0108 x2), mesh covers for pads (K0108
x2), thigh hip supports (K0108 x2), stealth gel pads, and wide footplates (K0108 x2) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara intrapulmonary percussive ventilator (IPV) 
device. 
 
You asked the Plan to pre-approve a Volara device. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that studies do not demonstrate any advantage of IPV 
over that achieved with good pulmonary care in the hospital environment, and there are no studies in the home 
setting. Based on this information, we decided that Medicare rules for coverage of a Volara device have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Volara intrapulmonary 
percussive ventilator (IPV) device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you do not feel safe to go home and you require a 
SNF level of care. The Plan denied your request. The Plan says the enrollee's condition does not meet the 
requirements for a SNF admission. 
 
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. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows that you have had clinical and functional status change 
and would require assessment by skilled therapy and skilled nursing. The documentation shows that your past 
level of function was modified independent with mobility and required some assist with activities of daily 
living, and there are no specified daily skilled therapy goals. Clinical documentation does not specify any daily 
skilled nursing needs; thus, daily skilled services are not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.