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

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee has mild cognitive impairment and 
a strong family history of Alzheimer's disease, this service is medically necessary. The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 there was no indication that the enrollee 
was suspected of having both AD and FTD--nor meeting the diagnostic criteria for both, the criteria for 
coverage have been met at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records provided support the 
need for the requested LTACH admission. The Plan denied your request. The Plan says the enrollee is 
receiving medically necessary acute and/or critical care and does not have clinical conditions that cannot be 
appropriately treated in the current hospital.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case.  
 
 Our physician reviewer found the enrollee with a past medical history of stroke with right-sided hemiplegia, 
dysphagia, and percutaneous endoscopic gastrostomy tube placement was admitted to the hospital with septic 
shock secondary to pneumonia, which was complicated by acute respiratory failure and acute renal 
insufficiency. The enrollee was intubated but is now on room air and has no need for vent weaning. The 
enrollee does not have complex wound 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the push handles (K0108). 
 
You asked the Plan to pre-approve the push handles. You say that the item should be covered. The Plan denied 
your request. The Plan says this is an item of convenience and does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the push handles (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 44180-59 billed for date of service May 16, 
2023.  
 
You asked the Plan to pay for procedure code 44180-59. You say that this was a necessary surgery. The Plan 
denied your request. The Plan says payment for code 44180-59 is bundled into payment for code 44820-51. 
 
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, we have confirmed that code 
44180-59 is a column two code to column one code 44820-51 with a modifier indicator of 0. The column two 
code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met.   
Please note that this is a billing issue with the provider, and they should not be billing you for the cost.  Any 
questions regarding billing you may receive for this surgery beyond your cost sharing should be directed to the 
Plan or the provider. Therefore, we decided that the Plan does not have to pay for procedure code 44180-59 
billed for date of service May 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Padcev. 
 
You asked the Plan to pre-approve the drug. You say that the enrollee has aggressive bladder cancer which 
progressed despite chemo and pembrolizumab as first and second line. You say that the trials were done in first 
line, unfortunately the enrollee has a bad disease and its urgent to use the best combination. The Plan denied 
your request. The Plan says Padcev is not medically necessary. 
 
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 the drug. Our reviewer says that Padcev 
is not medically necessary. Our physician reviewer found that while the enrollee has failed Keytruda it cannot 
be approved in combination with Padcev. However, Padcev can be approved as a single agent not with 
Keytruda. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Padcev.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing (U0002) provided on August 30, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory testing. You say that this service should be covered. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
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 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 COVID-19 testing (U0002) provided on August 
30, 2023, by an out-of-network (OON) provider.
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 enrollee will clearly benefit from acute rehab to 
optimize their level of functioning prior to returning home. The Plan denied your request. The Plan says the 
inpatient rehabilitation facility (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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 
was admitted for lumbar spine surgery. Medical problems are stable. 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. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for code 87624 provided to the enrollee on September 
19, 2022.

You asked the Plan to pay for this service. 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 code 87624 is not covered when billed with 
a screening diagnosis code. The Plan noted that the screening code for Human Papillomavirus (HPV) 
is G0476, which can be billed with the screening diagnosis code Z11.51. However, code 87624 is not 
a screening procedure code. The claim for code 87624 upheld as it is not billed correctly per 
Medicare guidelines.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that 
providers must report services correctly. Providers must report services with the appropriate code. 
In this case, code 87624 was billed in error as it cannot be reported with a screening diagnosis 
code. Based on this information, we decided that Medicare rules for coverage of this service have 
not been met. Therefore, we decided that the Plan does not
have to pay for code 87624 provided to the enrollee on September 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an over-the-counter (OTC) COVID-19 test provided on June 
26, 2023. 
 You asked the Plan to pay for an OTC COVID-19 test. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that OTC COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that starting on May 12, 2023, OTC COVID-19 tests 
are no longer covered by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a COVID-19 test have not been met. Therefore, we decided that the Plan does not have to pay for 
an over-the-counter (OTC) COVID-19 test provided on June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wig. 
 
You asked the Plan to pre-approve the wig. You say that the item should be covered. The Plan denied your 
request. The Plan says this is a non-covered item. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve the wig.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for dates of service July 3, 
2023, to July 9, 2023. 
 
You asked the Plan to pay for the billed services. You say that the claim was coded correctly. The Plan denied 
your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that diagnosis code group J18 has an Excludes1 note in relation to diagnosis 
code group J69.-. This means that diagnosis codes J18.9 and J69.0 cannot be reported together. Based on this 
information, we decided that the Medicare billing rules for the billed services have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99291 billed for dates of service July 3, 2023, to 
July 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional lithium-based battery (E2397) and 
adjustable height, detachable armrest (E0973). 
 
You asked the Plan to pre-approve an additional lithium-based battery and adjustable height, detachable 
armrest. The Plan denied your request. The Plan says the adjustable height armrest is denied as no evidence 
was provided that the enrollee's arm height is different from the available nonadjustable arm rests. The Plan 
also says the additional lithium battery is denied as the local coverage determination only allows one battery 
every three years. 
 
The Plan follows Medicare rules. Medicare rules say that only one battery is allowed at any one time. Medicare 
rules also say that the adjustable arm height option (such as code E0973) is covered if the beneficiary requires 
an arm height that is different from that available using nonadjustable arms and the beneficiary spends at least 
2 hours per day in the wheelchair. 
 
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 an additional lithium-based battery and 
adjustable height, detachable armrest. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found only one battery is allowed at a time every 3 years and there is no report or 
measurement indicating medical necessity for adjustable arm rests. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional lithium-based battery and adjustable height, detachable armrest 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional lithium-
based battery (E2397) and adjustable height, detachable armrest (E0973).
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 enrollee needs this care to regain strength. The 
Plan denied your request. The Plan says the enrollee's condition does not meet the criteria for an IRF 
admission.  
 
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 the enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 a grab bar. 
 
You asked the Plan to pre-approve a grab bar. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that this procedure is a block to see if the 
enrollee would benefit from the radiofrequency ablation to the right knee. The Plan denied your request. The 
Plan says the genicular nerve block 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 genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the enrollee 
has a history of right knee pain due to osteoarthritis. However, genicular nerve blocks and genicular nerve 
ablations are considered investigational and not medically necessary for the treatment of chronic knee pain. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unoccupied tie down (K0108). 
 
You asked the Plan to pre-approve an unoccupied tie down. You say that the enrollee is unable to ambulate 
independently and requires a K0825 base and all recommended components to meet their mobility, medical, 
and functional needs in their home.  The Plan denied your request. The Plan says as a tie down kit does not 
serve a primary medical purpose, it is statutorily non-covered and upheld. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also state that for equipment to be covered, it must be appropriate and needed for 
use inside the home.  
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. The item at issue 
in this appeal is also for use outside of the home. Although this item may be helpful, neither Medicare nor the 
Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-
approve an unoccupied tie down (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that a BiPAP is unsuitable because the 
enrollee's diagnosis is too severe. The Plan denied your request. The Plan says a home ventilator is not 
medically necessary for this patient because their needs can be met with an alternative device such as a BiPAP 
device with average volume-assured pressure support (AVAPS).   
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease and obstructive sleep apnea. 
However, the documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability and failure 
of such a device has not been documented. Therefore, the elements of the coverage criteria are not satisfied, 
and the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.