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

 
We decided that the Plan does not have to pay for a knee orthosis (L1852) provided on July 7, 2023. 
 
You asked the Plan to pay for a knee orthosis. You say that the item at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the item at issue 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 pay for a knee orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found 
that there was no recent injury, surgery or objective criteria of instability. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for a knee orthosis (L1852) provided on July 7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transfer to an out-of-network hospital. 
 
You asked the Plan to pre-approve transfer to an out-of-network hospital. You say that there are concerns with 
the care the enrollee is getting within the network, and you believe they will be better treated out-of-network. 
The Plan denied your request. The Plan says the records received do not indicate that the enrollee is in need of 
specialized services that are not available in the network. Transfer to an out-of-network hospital is not 
medically necessary. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 transfer to an out-of-network hospital. 
Our reviewer says that transfer to an out-of-network facility is not medically necessary or reasonable. Our 
physician reviewer found the enrollee underwent a cardiac catheterization, after which it was determined that 
cardiac surgery would be required. The enrollees surgery involved multiple procedures. While it is unfortunate 
that the enrollee has developed multiple complications (pneumonia, fluid overload, renal failure, 
gastrointestinal bleeding, Clostridium difficile, bacteremia), none of these complications are unusual given the 
extent of the enrollees cardiac surgery and the subsequent treatments required. Furthermore, all of these 
complications have been addressed in turn by the primary and consulting physicians. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transfer to an out-of-network hospital have not been met. Therefore, we decided 
that the Plan does not have to pre-approve transfer to an out-of-network hospital.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 84443, 82607, and 85025. 
We decided that the Plan does not have to pay for the services described by procedure code(s) 82306.  
 
You asked the Plan to pay for procedure codes 84443 82306 provided on July 6, 2023. You say that you would 
like the Plan to reconsider their denial of payment. The Plan says that the services are not covered as billed. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 84443, 82607, and 
85025.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 84443, 82607, and 85025.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
82306. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 82306 have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the services described by procedure code(s) 82306. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Watchman procedure/left atrial appendage closure 
(LAAC). 
 
You asked the Plan to pre-approve the services. You say that this si medically necessary. The Plan denied your 
request. The Plan says the records do not show participation in a shared decision-making encounter with an 
independent non-interventional physician. 
 
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 at issue is the medical necessity of implanting a LAAC device in this patient in whom there is 
elevated risk of thromboembolic stroke due to atrial fibrillation and elevated CHADS2VASC score. Anticoagulation is thought to be contraindicated owing to the risk of falls. While there is reference to 
consideration of the LAAC, there is no documentation of performance of an evidence-based shared decision-
making interaction on anticoagulation. As such, guidelines would not support implantation of a LAAC in this 
setting. In summary, LAAC placement would not be considered reasonable or medically necessary in this 
patients 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Watchman procedure/left atrial appendage closure (LAAC).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 skilled nursing visits. 
 You asked the Plan to pre-approve the skilled nursing visits. You say that the services are medically necessary. 
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 skilled nursing visits. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found documentation 
does not specify any unmet home health skilled nursing goals, acute clinical status changes, medication or plan 
of care changes or complex wounds. The records do not show that 3 additional home health skilled nursing 
visits are required to effectively provide treatment, care or services for the enrollee. 
 
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 skilled nursing visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 3 skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS Heart Failure (HF) system. 
 
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 recurrent congestive 
heart failure. The CardioMEMS was approved by the Food and Drug Administration (FDA) in 2014. 
Nonetheless, 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 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 a CardioMEMS Heart Failure (HF) system.
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 inpatient rehabilitation before being 
discharged home. The Plan denied your request. The Plan says admission to inpatient rehabilitation 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on May 9, 2023. 
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says ordering a multiclass panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter 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 pay for the definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
provided documentation did not sufficiently support this testing. There was no unexpected urine drug screening 
or signs of abuse/misuse that would warrant definitive testing, and the excessive drug classes tested did not all 
apply to this enrollee's clinical history. Therefore, the LCD criteria for definitive drug testing for 22 classes is 
not met.  
 
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 definitive UDT for 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on May 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 kyphoplasty (22513). 
 
You asked the Plan to pre-approve T12 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says while this enrollee has evidence of an acute vertebral compression fracture, 
retropulsion with impact upon the thecal sac is a relative contraindication. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 T12 kyphoplasty. Our reviewer says 
that the enrollee does not meet criteria for coverage. Our physician reviewer found there is magnetic resonance 
imaging corroboration of retropulsion and other plausible causes of 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 T12 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T12 kyphoplasty (22513).
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 had a three hour spine surgery and need therapy 
as you are without the ability to function normally. The Plan denied your request. The Plan says based on the 
available information, admission to IRF is not reasonable and necessary, as your condition does not meet the 
Medicare rules.  
 
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 based on the documentation provided, it is my opinion that the health plans denial 
should be upheld.  You do not require the intensity of services provided at an IRF.  Specifically, you are not 
shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  Your care 
needs can be met at a lower level of care (ex. skilled nursing facility/sub acute rehabilitation).  
 
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 pre-approve Dexamethasone. 
 
You asked the Plan to pre-approve Dexamethasone. You say that the enrollee needs for treatment of 
thrombocytopenia. 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 Dexamethasone.  
 
Benefits for Dexamethasone 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Heelex radiation therapy. 
 
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 radiation therapy 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
Dupuytren's contracture. The documentation includes clinic notes from the enrollee's primary care physician 
and from an orthopedic surgeon who referred her for a discussion on radiation. There are no radiation oncology 
clinic notes or justification of need by a radiation oncologist who examined the enrollee and her records and 
discussed the risks and benefits. The request for 20 dose calculations and 50 units of multileaf collimator 
(MLC) blocking would not be in accordance with standards of care.  It is not clear what is being offered to the 
enrollee. The criteria for coverage are not met and the services are not medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Heelex radiation therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says there is not a medical need to control the power options 
with a joystick. 
 
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 upgraded electronics. Our reviewer 
says that the requested upgraded electronics (E2311, E2313, E2377) are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation does not indicate that the 
enrollee does not have use of the upper extremity and can operate and control the power options using the 
switches that are included in the basic wheelchair. Therefore, the reviewer found that the requested upgraded 
electronics are not medically 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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural adhesiolysis procedure (62264). 
 
You asked the Plan to pre-approve epidural adhesiolysis. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational for the enrollee's condition. 
 
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 epidural adhesiolysis. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided medical records and a review of the current peer-reviewed medical literature 
do not document that use of the epidural adhesiolysis procedure has been shown in controlled studies in a 
Medicare-approved journal to result in sustained, long-term health benefits in Medicare patients with radiculopathy, lumbar region and postlaminectomy syndrome, not elsewhere classified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural adhesiolysis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an epidural adhesiolysis procedure (62264).