Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that 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 enrollee is medically stable with no medical complexity and does not need 
physician's supervision three (3) times a week in an IRF. No nursing needs identified or documented. At the 
current functional level, the enrollee needs physical therapy and occupational therapy, and the enrollee does not 
need specialized and intensive therapies consisting of at least 3 hours of therapy per day at least five (5) days 
per week with multidisciplinary approach in an IRF. Document does not support necessity for admission to an 
IRF. The complexity of the enrollee's medical, rehab, and nursing needs (combined complexity) does not 
require an acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. 
The enrollee's rehab needs can be safely provided in an alternate and low intensity setting such as in a skilled 
nursing facility (SNF). 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0150, D1110, D2330, D2331, D2332, D2740, D6740, and D6245) provide to the enrollee out of network on December 23, 2022, January 18, 2023, and January 19, 2023.
You asked the Plan to pay for out of network dental services. You say that you were misled into believing that you would be able to access dental services out-of-network.
You state that none of the in-network dentists are of good quality and you require these services out-of-network. The Plan denied your request. The Plan says the contract is clear that out of network dental services are not covered. Maximus upheld the Plans decision. This appeal was sent for an Administrative Law Judge (ALJ) hearing. The ALJ requested clarification on all services reviewed. Maximus reopened the case and amended the letter to include all codes reviewed.
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 more than Medicare coverage, the contract is clear that out of network dental services are not covered. Therefore, we decided that the Plan does not have to pay for dental services (D0150, D1110, D2330, D2331, D2332, D2740, D6740, and D6245) provide to the enrollee out of network December 23, 2022, January 18, 2023, and January 19, 2023.
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 you just had heart surgery and need this therapy. The 
Plan denied your request. The Plan says you do not meet the criteria for admission to an IRF. 
 
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 that you do not require treatment by multiple therapies. 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 continued use of a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that 
the provided medical notes indicate that the enrollee's pulmonary function testing shows combined obstructive 
and restrictive disease with air trapping, but specific values are not provided. There is no diagnosis of COPD, 
thoracic restrictive disease or neuromuscular disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued use of a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trazimera (Q5116), in combination with paclitaxel 
(J9267) and carboplatin (J9045). 
 
You asked the Plan to pre-approve Trazimera in combination with paclitaxel and carboplatin. You say that you 
believe the enrollee has some sort of human epidermal growth factor receptor 2 (HER2) amplification. You 
also say that based on the HER2 amplification the enrollee had, and current regimen does not seem to be 
working, this would be some kind of last-ditch effort. The Plan denied your request. The Plan says the clinical 
value and effectiveness of Trazimera in the setting of ovarian cancer have not been demonstrated in the peer-
reviewed literature. 
 
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 Trazimera in combination with 
paclitaxel and carboplatin. Our reviewer says that Trazimera in combination with paclitaxel and carboplatin is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of 
Trazimera (Q5116), in combination with paclitaxel (J9267) and carboplatin (J9045) is not FDA-approved for 
the enrollees diagnosis. The use is not supported by one of the major drug compendia or by clinical research 
that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal. Our reviewer 
also found that the use is not listed as not indicated, not supported, or not recommended in any of the 
compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trazimera in combination with paclitaxel and carboplatin have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Trazimera (Q5116), in combination with 
paclitaxel (J9267) and carboplatin (J9045).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on February 9, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that your claim for the DecisionDx-SCC test wad 
died in and you are requesting it be reprocessed and paid. The DecisionDx-SCC test is a covered Medicare 
benefit. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-
network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
February 9, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 5, 2022.
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 enrollee is medically improved and stable and does not need physician's 
supervision three (3) times a week in an IRF. No nursing needs identified or documented. At the current 
functional level, the enrollee needs ongoing physical therapy and occupational therapy in a skilled nursing 
facility (SNF). The enrollee does not need specialized and intensive therapies consisting of at least 3 hours of 
therapy per day at least five (5) days per week with multidisciplinary approach in an IRF. Document does not 
support necessity for admission to an IRF. The complexity of the enrollee's medical, rehab, and nursing needs 
(combined complexity) does not require an acute hospital inpatient rehab stay with an interdisciplinary 
approach to rehabilitative care. The enrollee's rehab needs can be safely provided in an alternate and low 
intensity setting such as in a SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 provided on December 17, 2022. 
 
You asked the Plan to pay for procedure code 99292. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the billing of code 
99292. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure code 99292 have been met. 
There is no documentation of critical care time spent with the enrollee on the date of service at issue. 
Therefore, we decided that the Plan does not have to pay for procedure code 99292 provided on December 17, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat paravertebral facet joint radiofrequency ablation 
(RFA). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show at least 50% reduction in pain for at least six months following 
the previous radiofrequency ablation procedures. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the LCD guidelines require 50% pain relief for six months. The previous RFA did not produce four 
months of pain relief. As the proper relief was not achieved, the request is deemed 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat paravertebral facet joint radiofrequency ablation (RFA).
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 services are medically necessary due to the 
enrollee's complex medical problems that have left them well below their baseline. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
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 does not require treatment by multiple therapies. 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 pay for a pneumatic compression device (E0675) provided to the enrollee on November 30, 2022.
You asked the Plan pay this claim. You say that this device should be covered by the Plan. The Plan denied your request. The Plan says the Medicare coverage criteria are not met.
The Plan follows Medicare rules. The rules state a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. There are insufficient medical records submitted with your request to demonstrate the enrollee meets any kind of criteria for this equipment. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Therefore, we decided that the Plan does not have for a pneumatic compression device (E0675) provided to the enrollee on November 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal molecular diagnostic test (81479) 
provided November 10, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you provide the Guardant Reveal molecular 
diagnostic test at the request of the ordering physician. The Plan denied your request. The Plan says Medicare 
does not cover services that are investigational due to unproven safety or efficacy, therefore the testing is not 
approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. Per DEX Diagnostics, Guardant Reveal is not covered by Medicare. 
Per NCCN (National Comprehensive Cancer Network) guidelines for Colon Cancer, Version 2.2023, there is 
insufficient data to recommend post-surgical ctDNA (circulating tumor Deoxyribonucleic acid) to estimate risk 
of recurrence or determine adjuvant therapy.  Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the Guardant Reveal molecular diagnostic test (81479) provided November 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires an interdisciplinary level of care 
to include case management to coordinate post-discharge needs, medical assistive device needs, and to provide 
education to their family on how to assist the enrollee once they are home.  The Plan denied your request. The 
Plan says admission to an IRF is 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 is experiencing weakness and cannot 
stand following a heart attack. The Plan denied your request. The Plan says that the IRF services you are 
requesting do not meet the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the enrollee's nursing, medical and rehabilitation needs does require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. There is 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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.