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

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service July 12, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the testing was needed to monitor possible 
opioid abuse. The Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 83789 billed for date of service July 12, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from June 8, 2023, to June 21, 2023. 
 
You asked the Plan to pay for SNF care. You say that the SNF services provided from May 23, 2023, to June 
21, 2023 were medically necessary. The Plan denied your request. The Plan says the enrollee did not require 
SNF services after June 7, 2023. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in an 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 pay for 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in an SNF setting. 
 
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 pay for SNF care provided from June 8, 2023, to June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an E0466 ventilator for the enrollee.

You asked the Plan to provide coverage for this device. You say that at the time of the appeal this ventilator
was medically necessary. 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 a ventilator is not eligible for reimbursement for any of the conditions described in this
RAD LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP
(E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for
conditions described in this RAD policy will be denied as not reasonable and necessary. The Plan notes this
ventilator is being requested to provide RAD volume assured pressure support, which is not a covered
indication by Medicare.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say ventilators used to provide
CPAP or bi-level CPAP therapy will be denied as not reasonable and necessary. This ventilator was requested
to provide CPAP.bi-level CPAP therapy. Therefore, we decided that the Plan does not have to provide
coverage for an E0466 ventilator for the enrollee.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency services (99285) provided on June 9, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed code is 
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 99285 is "Emergency department visit for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making". 
 
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 use of code 99285 is 
supported by the records provided. Our reviewer found that the enrollee had a comprehensive history and exam 
as well as work up. The enrollee also received dialysis in the emergency room (ER). The risk of morbidity, 
mortality and complications was high and required urgent/emergent dialysis in the ER to prevent further 
decompensation. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the emergency services (99285) provided on June 9, 2023.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting LTACH services for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an LTACH care. 
 
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 that the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve low-dose radiation therapy for osteoarthritis. 
 
You asked the Plan to pre-approve low-dose radiation therapy. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested treatment is 
experimental/investigational. 
 
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 low-dose radiation therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the provided medical records and review of the current peer-reviewed 
medical literature do not document that use of low-dose radiation therapy has been shown in controlled studies 
in a Medicare-approved journal to result in sustained long-term health benefits in patients with 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 low-dose radiation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve low-dose radiation therapy for osteoarthritis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper and lower partial dentures.

You asked the Plan to pre-approve the dental services. 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 Plan's coverage rules apply in this case. Though the Plan offers a
dental benefit in excess of Medicare coverage, certain limitations apply. The previous determination stated that
the Plan did not provide sufficient documentation to support that you had exhausted the benefit limit for partial
dentures; however, the Plan has included the medical records and claim showing that you previously received a
partial denture on March 5, 2021. You are not eligible for a new partial denture until March 5, 2024. Therefore,
we decided that the Plan does not have to pre-approve upper and lower partial dentures.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE). 
 
You asked the Plan to pre-approve prostate artery embolization. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the medical evidence 
showing the procedure helps and it is safe is very low quality. 
 
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 prostate artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the most recent American Urological Association (AUA) guidelines do not 
recommend this procedure outside of a clinical trial setting due to the heterogeneity in the available literature 
and safety concerns regarding radiation exposure, postembolization syndrome, vascular access, technical feasibility, higher clinical failure rate compared with more traditional methods. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve prostate artery embolization (PAE).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the enrollee urgently needs this 
device due to worsening heart failure. The Plan denied your request. The Plan says that this treatment has not 
been proven to help. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time 
the CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's 
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on May 1, 2023. 
 
You asked the Plan to pay for 81226. You say that this code was denied in error. The Plan denied your request. 
The Plan says the correct code would be 81479. 
 
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 81226 is CYP2D6 (cytochrome P450, family 2, 
subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, 
*10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN). 
 
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 81226. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the procedure report describes multiple genes were tested, which should be reported with unlisted molecular pathology code 81479. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 81226 have not been met. Therefore, we decided that the Plan does not have to 
pay for laboratory testing provided on May 1, 2023.
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 the services should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as 
the enrollee does not meet the clinical requirements to be approved. 
 
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 in this case the enrollee was admitted with acute on chronic respiratory failure. The 
record indicates that the enrollee is improving but still requires acute care services before transitioning to a 
lower level of care. The enrollee continues to receive acute care services, and these have not been denied.  The medical record does not indicate that the enrollee requires services that the enrollee is not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. The requested service cannot be 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 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 the enrollee requires antibiotic coverage. You say 
that the enrollee is having current symptoms of congestive heart failure. You also say that the provider and the 
enrollee agree on this treatment plan. The Plan denied your request. The Plan says there is no need for an 
intensive rehabilitation program.  
 
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 provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no 
documentation of a need for an intensive rehabilitation program. The reviewer also found that there 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. Therefore, the reviewer found that the requested IRF 
admission 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 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 genicular radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve genicular RFA. You say that the long-term benefits of genicular RFA are 
well-documented. The Plan denied your request. The Plan says this procedure is experimental/investigational. 
 
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 RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental/investigational therapy and is the subject of ongoing clinical 
trials. 
 
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 RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular radiofrequency ablation (RFA).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Iovera procedure (64640, 76942). 
 
You asked the Plan to pre-approve the Iovera procedure. 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 the Iovera procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found limited published, large-scale, long-term peer-reviewed literature shows Iovera 
(cryoneurolysis) to be an effective and/or safe treatment for knee osteoarthritis. Further studies are needed to 
corroborate Iovera (cryoneurolysis) safety and efficacy is as good as or better than standard treatment 
modalities for knee osteoarthritis (medications, physical therapy modalities, glucocorticosteroid injections, 
and/or viscosupplementation). There is no compelling rationale presented, or extenuating circumstances noted 
to support the medical necessity of this request as an exception. 
 
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 Iovera procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Iovera procedure (64640, 76942).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that you would like to request reconsideration of 
the denied shower chair. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VivAer procedure (30469). 
 
You asked the Plan to pre-approve a VivAer procedure. 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 a VivAer procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided medical records and review of the current peer-reviewed medical literature 
do not document that use of the VivAer procedure has been shown in controlled studies in a CMS-approved 
journal to result in sustained long term health benefits in patients with nasal valve collapse causing nasal blockage. 
 
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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a VivAer procedure (30469).