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

 
We decided that the Plan does not have to pre-approve laparoscopy with gastric bypass and Roux-en-Y 
gastroenterostomy. 
 
You asked the Plan to pre-approve gastric surgery. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the enrollee does not have a body-mass index of 35 or greater than the 
records indicate evidence of esophageal dysmotility and dysphagia. 
 
The Plan follows Medicare rules. Medicare rules state that Roux-en-Y gastric bypass may be covered for 
certain indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve gastric surgery. Our reviewer says that 
the enrollee does not meet criteria for this surgery. Our physician reviewer found the enrollee has history of 
sleeve gastrectomy in 2020 for the treatment of obesity and related comorbidities. The enrollee now has a 
body-mass index of 32.2. Symptoms in the documentation are described as mild, with treatment of once-daily omeprazole. The surgeon's documentation suggests it is unclear why the enrollee is having gastrointestinal 
discomfort and the sleeve does not appear to be the problem. Endoscopy shows a normal esophagus and Z-line 
as well as a normal duodenal bulb. It is not clear that the proposed operation will alleviate symptoms and the 
body-mass index does not qualify for bariatric surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of gastric surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve laparoscopy with gastric bypass and Roux-en-Y gastroenterostomy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi (J9173). 
 
You asked the Plan to pre-approve Imfinzi. You say that the request is medically necessary. The Plan denied 
your request. The Plan says the requested use of this drug is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 
 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 Imfinzi. Our reviewer says that the 
requested use of Imfinzi is not supported. Our physician reviewer found the FDA has approved maintenance 
Imfinzi for unresectable stage III non-small cell lung cancer (NSCLC) whose disease has not progressed 
following concurrent platinum-based chemotherapy and radiation therapy. Evidence exists for inoperable stage 
III non-squamous cell lung cancer but not among those that were resected. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi (J9173).
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 at the time of the appeal, these services were
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 the medical records show your ability to participate in intensive therapy
was described as limited by the hospital physical therapist, given the limitations of weakness, balance
problems, and fatigue with any type of activity.

The Plan is correct in this case. 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. The
medical records do not reflect that at the time of the appeal, you were able to either benefit from or be able to
participate in the type of rehabilitation program required in an IRF admission. 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 provide coverage for a prosthetic addition to include an endoskeletal
knee-shin system and foot (L5828, L5845, L5848, L5856, L5986, L5987).

You asked the Plan to provide coverage for these items. The Plan denied your request. The Plan says the
medical records do not support the requested items. Maximus overturned the Plans denial. The Plan requested a
reopen and noted that while the enrollee's physician alleges that a K3 foot and K3 knee are necessary, this is
not consistent with available medical history. At the time of the appeal, the enrollee was using an assistive
device (crutch, cane, walker) and had a power wheelchair approved December of 2022. This is not consistent
with K3 ambulation.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. Medicare covers items that meet, but do not exceed,
the enrollee's needs, and the medical records must have specific documentation to support coverage.

Based on the medical records provided, there is not documentation to show the enrollee meets the criteria for a
K3 knee and foot, nor do they show why another knee and foot would not meet the enrollees needs. Therefore,
we decided that the Plan does not have to provide coverage for a prosthetic addition to include an endoskeletal
knee-shin system and foot (L5828, L5845, L5848, L5856, L5986, L5987).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Emgality. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. 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 Emgality.   
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Barostim Neo implantation. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has severely reduced left 
ventricular function. The Barostim Neo system was approved by the Food and Drug Administration (FDA) in 
2019 for use in patients with refractory heart failure who remain symptomatic despite treatment with guideline-
directed medical therapy, are New York Heart Association (NYHA) Class III, have an ejection fraction less 
than 35 percent, and are not candidates for bi-ventricular pacing. There remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of Barostim Neo in 
patient management. As a result, at this time the Barostim Neo system is not considered medically reasonable 
and necessary in the 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Barostim Neo implantation.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee cannot be safely discharged home. They 
require rehabilitation and SNF care in order to get stronger. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
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 that 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 have 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 a 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 pre-approve a continuation of SNF care.
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 are medically necessary due 
to the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee can safely 
receive this care in a skilled nursing facility (SNF) or at home with home health services or in an outpatient 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. 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 they are 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography angiography (CTA) of the pelvis. 
 
You asked the Plan to pre-approve pelvis CTA. You say that this is needed to see if you qualify for prostate 
artery embolization. The Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 pelvis CTA. Our reviewer says that you 
meet criteria for this testing. Our physician reviewer found CTA of the pelvis in order to assess arterial supply 
of the prostate is reasonable prior to planning prostate artery embolization. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pelvis CTA have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography angiography (CTA) of the pelvis.  
 
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 Group 3 power wheelchair (PWC) (K0861) with 
multiple power options and accessories. 
 
You asked the Plan to pre-approve Group 3 PWC. You say that without this wheelchair the enrollee will 
continue to be unsafe. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
multiple power options to qualify for a Group 3 power wheelchair with multiple power options. 
 
The Plan follows Medicare rules. Medicare rules state that a Group 3 power wheelchair with multiple power 
options may be covered if 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 Group 3 PWC. Our reviewer says that 
the enrollee does not meet criteria for this power wheelchair. Our physician reviewer found the enrollee does 
not have high risk for skin breakdown, use a catheter intermittently, have spasticity, or require an alternative 
means of managing the wheelchair/s power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Group 3 PWC have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC) (K0861) with multiple power options and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulator. 
 
You asked the Plan to pre-approve the nerve stimulator. You say that this procedure is necessary due to the 
failure of conservative treatments to address pain and restore function. The Plan denied your request. The Plan 
says the request 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 nerve stimulator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Sprint peripheral nerve stimulator is considered experimental/investigational 
and is not medically necessary for the treatment of chronic 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 nerve stimulator. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a SPRINT peripheral nerve stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture office visit billed with code 99202 for
August 25, 2022.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the provider type is not covered.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case.

We looked at the file and Medicare rules. The previous determination stated that the Plan did not have to waive
the copayments for the acupuncture services but had to pay for the office visit because they did not support
their denial. However, the file clearly shows that the provider type is not covered per the Plan's rules.
Specifically, the file shows that the services were performed by a Licensed Acupuncturist (LAC) and were not
performed under the supervision of a physician, PA, or NP/CNS. Therefore, we decided that the Plan does not
have to pay for the acupuncture office visit billed with code 99202 for August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA disc allograft intervertebral disc augmentation 
procedure. 
 
You asked the Plan to pre-approve VIA disc allograft intervertebral disc augmentation procedure. You say that 
you are requesting reconsideration for the denied claim. The Plan denied your request. The Plan says medical 
studies haven't proven this requested procedure is helpful for the enrollee's health. 
 
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 VIA disc allograft intervertebral disc 
augmentation procedure. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has 
cervical stenosis. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested service. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VIA disc allograft intervertebral disc augmentation procedure have not been 
met. Therefore, we decided that the Plan does not have to pre-approve VIA disc allograft intervertebral disc 
augmentation procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 skilled nursing visits, 3 physical therapy visits and 22 
aide visits. 
 You asked the Plan to pre-approve the 3 skilled nursing visits, 3 physical therapy visits and 22 aide visits. You 
say that the enrollee has not received care for a month and needs services quickly. The Plan denied your 
request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 3 skilled nursing visits, 3 physical 
therapy visits and 22 aide visits. Our reviewer says that the home health services are not medically reasonable 
and necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The 
enrollee does not have documented skilled therapy needs. The enrollee is functioning at a level commiserate 
with a lower level of care. The services cannot be approved at this time. 
 
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 3 skilled nursing visits, 3 physical therapy visits, and 22 aide visits have not 
been met. Therefore, we decided that the Plan does not have to pre-approve 3 skilled nursing visits, 3 physical 
therapy visits and 22 aide visits.
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 require a SNF level of care and under 24-hr 
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 you do not have documented skilled nursing needs. You do not have documented 
skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or 
to prevent deterioration of your condition. Your care needs, custodial and intermittent, can, as a practical 
matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.