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

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that the items should be covered. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot 
orthotics.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services (T1019). 
 
You asked the Plan to pre-approve personal care services. You say that providing more hours for home care 
Consumer Directed Personal Assistance Program (CDPAP) is indicated and medically necessary for this 
patient. The Plan denied your request. The Plan says personal care services are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of personal care services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal 
care services (T1019).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for one unit of procedure code 83520. We decided that the Plan does not 
have to pay for two units of procedure code 83520.  
 
You asked the Plan to pay for three units of procedure code 83520 billed for date of service March 2, 2023.. 
You say that this code is supported in the medical records. The Plan says that this code is not supported. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for three units of procedure code 83520. Our reviewer says that 
this code is supported, but not for the number of units reported. Our reviewer found that only one unit of 
procedure code 83520 is supported in the medical records provided. The other two units are not supported. 
 
We decided that the Plan has to pay for one unit of procedure code 83520.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of one unit of procedure code 83520 have been met. Therefore, we decided that the 
Plan has to pay for one unit of procedure code 83520.  
 
We also decided that the Plan does not have to pay for two units of procedure code 83520. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of two additional units of procedure code 83520 have not been met. Therefore, we 
decided that the Plan does not have to pay for two units of procedure code 83520. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from 
October 6, 2022, to October 8, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the treating physician exercised their 
expert opinion in electing to admit this patient out of concern that the patient's symptoms were attributed to an 
escalating clinical condition. The Plan denied your request. The Plan says the clinical does not support a 
reasonable expectation that the enrollee would require hospital services extending beyond two midnights. 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee was admitted to inpatient status on October 6, 2022 at 22:17. The 
History & Physical Assessment and Plan included: We will discontinue antibiotic treatment at present. 
Patient did not have any further episodes of diarrhea since she presented to the medical surgical unit. If her 
diarrhea remains resolved, she can be discharged later on today and be followed on the outpatient basis. 
The record did not show that at the time of inpatient admission it was reasonable for the admitting physician to 
expect that the patient's necessary hospital care (including earlier emergency department and/or observation 
care) would span two midnights with supporting documentation of the patients history and comorbidities, 
signs and symptoms, current medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from October 6, 2022, to 
October 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there were/are multiple plausible pathologic sources of significant pain generation. 
The non-radiating midline back pain, the noted pain-aggravating factors (standing, walking, exercise, physical 
therapy, leaning back, and more so leaning forward), pain-relieving factors (heat, cold, and medications), and 
the diminished and painful spinal motion were/are all non-specific to any pathologic entities. There is no 
compelling rationale presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0821) and 
additional items and accessories (codes E1028, K0773 x2, and E0973 x2).  
 
You asked the Plan to pre-approve a group 2 standard power wheelchair and additional items and accessories. 
You say that you have been newly diagnosed with peripheral vascular disease, cannot walk anymore, and you 
really need this wheelchair. The Plan denied your request. The Plan says the criteria for coverage has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 group 2 standard power wheelchair 
and additional items and accessories. Our reviewer says that the group 2 power wheelchair is not medically 
necessary. Our physician reviewer found you are noted to be able to ambulate household distances, and are 
noted to have 4 out of 5 motor strength. There is insufficient documentation regarding your level of mobility 
and function regarding your ability to perform daily activities. Our reviewer found that you are noted to have 
Chronic Obstructive Pulmonary Disease (COPD) and are limited by your shortness of breath but there are no 
objective measurements regarding your oxygen saturation and level of mobility before desaturation. Our 
physician reviewer also found that you are noted to be unable to propel a manual wheelchair due to shoulder 
pain, but the clinical documentation does not indicate shoulder related pathology. 
 
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 group 2 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power 
wheelchair (K0821) and additional items and accessories (codes E1028, K0773 x2, and E0973 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the culture identified with code 87086 for date of service 
April 11, 2023. 
 
You asked the Plan to pay for the culture identified with code 87086. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes that must be 
billed in order for code 87086 to be covered.  
 
We looked at the file and Medicare rules. Review of the file shows that code 87086 was billed with diagnosis 
C67.0 (Malignant neoplasm of trigone of bladder). This diagnosis is not listed as an appropriate diagnosis code 
for this procedure code billed. Based on this information, we decided that Medicare rules for coverage of the 
culture identified with code 87086 have not been met. Therefore, we decided that the Plan does not have to pay 
for the culture identified with code 87086 for date of service April 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization (36246, 36247). 
 
You asked the Plan to pre-approve genicular artery embolization. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental therapy and is the subject of ongoing 
clinical trials. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization (36246, 36247).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee to receive the care needed. The Plan denied your request. The Plan says that that the enrollee could receive care in another setting.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our Medical Director states that the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical conditions appear improved on stable medications with no issues that appear to require a physician's evaluation three or more times per week in a hospital setting. The patient does require physical therapy and occupational therapy services, but the medical records provided do not clarify why the patient requires an intensive inpatient rehabilitation therapy program. Provided medical records do not support that the intensive inpatient rehabilitation therapy program is necessary and that therapy at a lower level of care such as in a skilled nursing facility is not appropriate for the patient. The patient would be expected to participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility however the medical records do not support a complexity of needs to require an acute inpatient rehabilitation facility over a skilled nursing facility. Our Medical Director found that the enrollee's condition does not meet Medicare criteria for IRF 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 has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven additional home health physical therapy (PT) 
visits. 
 You asked the Plan to pre-approve home health 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. 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the physical 
therapy note dated June 27, 2023 states that you have been receiving physical therapy for a decline in function 
and mobility. The note dated October 2, 2023 indicates you are sitting with leg exercises. You need moderate 
assistance with transfers. You do not require the services of a skilled physical therapist. You have reached your 
maximum level of function. The seven continued home health PT visits are not medically necessary based on 
the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve seven additional home health physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device (22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented, or extenuating circumstances noted to 
support the medical necessity of this request as an exception. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22869, 22870).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Medicare Part B prescription drugs provided to the enrollee from January 3, 2022, to January 6, 2022.
You asked the Plan to waive the coinsurance for the Medicare Part B prescription drugs. You say that you disagree with the cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the Plan's denial. The Plan requested a reopening and stated that the incorrect criteria were applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 10% coinsurance for Medicare Part B prescription drugs up to a $300 out of pocket maximum.
The enrollee has been asked to pay a 10% coinsurance for the Medicare Part B prescription drugs. This item/service falls within the Medicare Part B prescription drugs up to a $300 out of pocket maximum benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Medicare Part B prescription drugs provided to the enrollee from January 3, 2022, to January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
You asked the Plan to pre-approve SSBCI benefits. You say that you believe you qualify for these benefits. The Plan denied your request. The Plan says that you do not meet the criteria to be eligible for SSBCI benefits. Maximus overturned the Plan's denial because they did not include relevant medical records. The Plan has requested a reopening and now provided medical records.
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a documented chronic condition that is life threatening or significantly limits the health or function of the enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an eligible condition that meets all the required criteria. Your physician confirmed that you do not need intensive care management and are not at high risk for hospitalization. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
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 inpatient rehabilitation facility is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the requirements 
for admission to an inpatient rehabilitation 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's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. 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.