Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. This enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS) during sleep as an outpatient. This has not been shown to fail as an 
outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need a minimum of five hours of occupational 
and physical therapy due to your neuromuscular disorders in order to help you get back to baseline. You say 
want to go back to living independently. The Plan denied your request. The Plan says the IRF care is not 
medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility. 
 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 You were admitted for surgical repair of a hip fracture after a fall. Your medical 
problems are stable, and there are no complex nursing or rehabilitation needs. You do 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. 
 
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: 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 without physical therapy, the enrollee's quality of life 
would be diminished. The Plan denied your request. The Plan says the IRF care is not medically necessary, and 
the enrollee's needs can be met at a lower level of care such a skilled nursing facility 
 
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 admitted for a reaction to contract dye during a diagnostic procedure. 
The enrollee's medical problems are stable, and there are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, 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. 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for code J3490 provided to the enrollee on July 12, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that the unlisted code J3490 for NDC 00409115902 was properly denied, because Bupivacaine is a local anesthetic agent that cannot be separately reimbursed from the injection procedure 27096 that was billed on the same claim. Per Medicare Claims Processing Manual Chapter 12, Section 30.5.C - Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy): A therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration, is for the administration of substances/drugs. The fluid used to administer the drug (s) is incidental hydration and is not separately payable. If performed to facilitate the infusion or injection or hydration, the following services and items are included and are not separately billable: 1. Use of local anesthesia; 2. IV start; 3. Access to indwelling IV, subcutaneous catheter or port; 4. Flush at conclusion of infusion; and 5. Standard tubing, syringes and supplies.
Payment for the above is included in the payment for the chemotherapy administration or nonchemotherapy injection and infusion service. The Plan has correctly denied J3490 for payment as payment for the local anesthetic is included in the payment for the chemotherapy administration or nonchemotherapy injection and infusion service.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, code J3490 could not be paid separately based on the Medicare billing guidelines for the type of service provided. Therefore, we decided that the Plan does not have to pay for code J3490 provided to the enrollee on July 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  the initial positron emission tomography (PET) scan for 
metastatic lung cancer. 
 
You asked the Plan to pre-approve the PET scan. You say that  the PET scan is medically necessary. The Plan 
denied your request. The Plan says the initial PET scan for metastatic lung cancer is not necessary for radiation 
planning or restaging. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee's maintenance treatment has 
included a recent brain magnetic resonance imaging (MRI) showing progression of the metastatic non-small 
cell lung cancer in the brain. A PET scan is not considered a standard of care for surveillance of metastatic 
disease. Please note, a new computed tomography (CT) scan would be standard for care, and a PET ordered if 
any discrepancies were found, for which additional imaging would be needed.   
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve  the initial positron emission tomography (PET) scan for metastatic lung cancer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Bioness L300 Go System. 
 
You asked the Plan to pre-approve a Bioness L300 Go System. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that neuromuscular electrical stimulation is covered when 
specific 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 Bioness L300 Go System. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the Bioness L300 Go System functional electrical stimulation 
system at issue in this case meets all Medicare criteria for medically reasonable and necessary for the enrollee. 
Provided records do not document that the enrollee has completed a training program which consists of at least 
32 physical therapy sessions with the device over a period of three months. 
 
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 Bioness L300 Go System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Bioness L300 Go System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies haven't proven the Myopro Motion G to be helpful for the treatment of 
the health problem. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for 
neuromuscular conditions, peripheral nerve conditions, or this patient's condition. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long term outcomes for this patient. There is insufficient evidence in the literature 
that this device will increase  participation in bimanual activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a MyoPro orthotic device (L8702).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health physical therapy. 
 
You asked the Plan to pre-approve the therapy. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the services requested are not medically 
necessary. 
 
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. Our doctor found that this denial is for June 2023. There are no records provided 
by the plan after November 2022. The plan has not provided sufficient records to support their rationale for 
denial. Therefore, we decided that the Plan has to pre-approve home health physical therapy.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneDose Genetic Response Report provided on 
December 14, 2022, and billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 
81328, and 81335. 
 
You asked the Plan to pay for the GeneDose Genetic Response Report. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this test should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the GeneDose Genetic Response Report 
have not been met. Therefore, we decided that the Plan does not have to pay for the GeneDose Genetic Response Report provided on December 14, 2022, and billed with codes 81225, 81226, 81227, 81231, 81232, 
81240, 81241, 81291, 81306, 81328, and 81335.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient stay provided from November 8, 2022, to 
November 9, 2022. 
 You asked the Plan to pay for the inpatient stay. You say that the inpatient stay was medically necessary at the 
acute level of care. The Plan denied your request. The Plan says this stay was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient stay. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record did not show that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient stay provided from November 8, 2022, to November 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a maxillary partial denture (D5213) provided on 
February 27, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 27, 2023. 
Therefore, we decided that the Plan does not have to pay more for a maxillary partial denture (D5213) provided 
on February 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, 
E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's upper limb strength and function are adequate for the enrollee to be able to 
control the power options using their own switches which are included in the allowance of these power options. 
 
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 items. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the requested electrical accessories are not medically necessary as the enrollee does have use of the 
upper extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76641-LT, 76641-RT) provided on November 02, 2022.
You asked the Plan to pay for this claim. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that per the Medicare Medically Unlikely Edit (MUE) Practitioner Services sheet Effective 10-01-2022, code 76641 has an MUE value of 1, and an MUE Adjudication Indicator (MAI) of 2 indication this is a date of service edit. Please note that the MUE value for code 76641 changed from 2 to 1, as of the July 1, 2022, update. As the date of service in question is November 02, 2022, the new MUE value of 1 would apply.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, this claim could not be paid as billed due to the MUE value of code 76641 at time of service. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for the services (76641-LT, 76641-RT) provided on November 02, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE). 
 
You asked the Plan to pre-approve PAE. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that PAE is only 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 PAE. Our reviewer says that the 
documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has lower urinary tract symptoms (LUTS) due to benign prostatic 
hypertrophy (BPH). Prostate-specific antigen was 14.3 ng/mL and biopsy was benign on April 25, 2022. Prostate size is 126 gm. The records do not show that the enrollee has hemorrhage of the prostate. Prostatic 
arterial embolization (PAE) is considered an experimental technique to treat symptomatic BPH. Very limited 
studies have demonstrated possible short-term safety and efficacy.  The most recent 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 (eg, transurethral resection of 
the prostate). Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PAE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve prostate artery embolization (PAE).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy (J9228). 
 
You asked the Plan to pre-approve Yervoy. You say that the requested drug is beyond the scope of a clinical 
trial. The Plan denied your request. The Plan says the provided records support that the enrollee is part of a 
clinical trial. The Plan also says the requested drug is a routine cost for the clinical trial and therefore not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Yervoy as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Yervoy (J9228).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blepharoplasty (15821) provided on October 20, 2022. 
 
You asked the Plan to pay for the blepharoplasty. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the service was cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the blepharoplasty have not been met. Therefore, we decided that the Plan does not have to pay for 
the blepharoplasty (15821) provided on October 20, 2022.