Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the device is indicated. The Plan denied 
your request. The Plan says the device remains of uncertain value. 
 
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 requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure (CHF). Published expert opinion in the 
cardiology literature is supportive of the clinical usefulness of CardioMEMS. 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 this enrollees 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction 
device. You say that the records provided support the need for the procedure in dispute. The Plan denied your 
request. The Plan says the requested procedure 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 insertion of an 
interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the insertion of an 
interlaminar/interspinous process stabilization/distraction device is not considered medically reasonable and 
necessary in this case. Our physician reviewer found interlaminar spacer devices are experimental. More research is 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 insertion of an interlaminar/interspinous process stabilization/distraction 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an 
interlaminar/interspinous process stabilization/distraction device.
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 is requested 
for the enrollee's current needs and cannot safely be met at a lower level of care. The Plan denied your request. 
The Plan says the enrollee does not meet the criteria for inpatient rehabilitation 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 nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary as the 
requested facility is the only facility in the region to manage the enrollee's complex medical needs. The Plan 
denied your request. The Plan says the enrollee's needs can be met at an alternate level of care. 
 
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 that the enrollee appears to be improving and should only require short-term 
additional acute care services that can safely be administered at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories K0822, 
E2361, E1028, K0108, E2609, E2615, E0955 and E0973. 
 
You asked the Plan to pre-approve a power wheelchair. You say that the enrollee has difficulty using a manual 
standard wheelchair to safely access their environment and the community. The Plan denied your request. The 
Plan says the enrollee does not meet medical necessity requirements for the requested power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a power wheelchair is being requested for use in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories K0822, E2361, E1028, 
K0108, E2609, E2615, E0955 and 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 you are appealing the denial. The Plan denied your 
request. The Plan says that the services do not meet the requirements for approval and that the necessary 
services can be provided safely in other settings. 
 
  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive copayments charged for ambulance services and imaging services provided May 3, 2022, to June 24, 2022
You asked the Plan to waive these copayments. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract criteria. The Plan notes that based on the procedure code billing by the provider, 78306 for bone and/or joint imaging for whole body, the $50 copayment applies.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 copayment for certain types of imaging and $225 copayment for ambulance transport. You have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive either of these copayments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the $1000 hearing aid benefit for hearing aids purchased on March 9, 2022.
The enrollee asked the Plan to pay this benefit. The Plan denied this request. The Plan says this benefit was used on June 21, 2021 and was not eligible for payment on the date of service for 2022. Maximus overturned the Plans denial for missing information in the case file showing payment on June 21, 2021. The Plan requested a reopen and provided proof of payment.
The Plan is correct in this case. Medicare does not pay for hearing aids or related services. The Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays a $1000 benefit for hearing aids every two years.
The records show this benefit was paid on June 21, 2021. Therefore, per the Plan contract, this benefit would not have been available again until June 22, 2023. Therefore, this benefit could not be applied to the March 9, 2022, purchase. Therefore, we decided that the Plan does not have to pay the $1000 hearing aid benefit for hearing aids purchased on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye exam provided on June 25, 2022.
You asked the Plan to pay for the routine eye exam. You say that this was only a routine maintenance service. The Plan denied your request. The Plan says that this service is not covered by the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the routine eye exam provided on June 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on April 11, 2022, to April 20, 2022, at the Diagnosis Related Group (DRG) originally billed.
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this claim should be paid as billed. The Plan denied your request. The Plan says the records provided do not support the DRG billed. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information.
Our Medical Director looked at the case file and the reopen request. At issue is the DRG downgrade from DRG 064 (Intracranial hemorrhage or cerebral infarction with major complication or comorbidity) to DRG 065 (Intracranial hemorrhage or cerebral infarction with complication or comorbidity). The enrollee was a then 91-year-old woman with a medical history that included atrial fibrillation, stroke, and hypertension, who was admitted to the hospital on April 11, 2022, with an acute ischemic stroke with right sided paresis and expressive aphasia. At the time of admission, the lungs were clear bilaterally, and the SpO2 was 99%. The enrollee was transferred to inpatient hospice care on April 20, 2022. The enrollee was stable at the time of discharge, was in no acute distress, and there was no increased work of breathing. The new and material evidence submitted by the Plan supports the Plan's DRG downgrade to DRG 065 (Intracranial hemorrhage or cerebral infarction with complication or comorbidity). The enrollee did not require significant evaluation and management of a major complication or comorbidity while in the hospital, as there was no arterial blood gas testing, no high flow oxygen administration, no provision of BiPAP, and/or use of mechanical ventilation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided on April 11, 2022, to April 20, 2022, at the Diagnosis Related Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stellate ganglion block. 
 
You asked the Plan to pre-approve a stellate ganglion block. 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 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 a stellate ganglion block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have a diagnosis of left upper limb causalgia (ICD-10 G56.42) and low back 
pain with radiation into the left lower extremity over the knee. You were status post left shoulder repair after 
suffering extensive left shoulder and bicep damage. After surgery you lost 70% use of her left arm, had 
excruciating arm pain, and skin occasionally appeared mottled and felt cold to the touch. The clinical exam showed reflex sympathetic dystrophy (RSD)/complex regional pain syndrome (CRPS) with neck pain radiating 
into the left upper extremity over the shoulder and complex regional pain syndrome of the left lower limb. Pain 
was rated nine of out 10. You received physical therapy, chiropractic manipulation, and cognitive behavioral 
therapy. The clinical information provided does not show two or more of the following findings: Change in 
feeling/sensation when touched, change in temperature and/or color of skin/vasomotor changes, swelling or 
seating that is not normal, change in hair, skin, or nails look, decreased range of motion, or loss of muscle 
control. Therefore, you do 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 a stellate ganglion block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a stellate ganglion block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
treatment. The Plan denied your request. The Plan says the basivertebral nerve has not been shown to be the 
cause of pain. 
 
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 requested services. Our physician 
reviewer found that Medicare guidelines consider this type of system unproven and not medically necessary.  
Large well-designed studies in the peer review scientific literature comparing stand-alone use of Intracept 
device to established surgical decompression are needed.  Published studies do not demonstrate any long-term health outcome advantage with the use of Intracept as an 
alternative to standard surgical treatment. In this case, the review has determined that the requested Intracept 
procedure is not medically reasonable or necessary 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99308 provided to the enrollee on January 27, 2022.
You asked the Plan to pay for procedure code 99308. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for procedure code 99308 provided to the enrollee on January 27, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 1, 2022.
You asked the Plan to pay for procedure code 76641. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four units of code 87481 and two units of code 87801 billed 
for November 17, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed units are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 services Our reviewer says that the 
records do not support the billed units. Our physician reviewer found that the record shows that candida was 
not detected and does not specify what exact infectious candida organisms were tested. It cannot be verified 
that more than one unit of code 87481 was performed. The description of code 87801 includes multiple 
organisms. It is not appropriate to report more than one unit for the same sample on the same date of service.  
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 pay for four units of code 87481 and two units of code 87801 billed for November 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination sit to stand frame/table system, any size 
including pediatric, with seat lift feature, with or without wheels (E0637) and durable medical equipment 
(DME), miscellaneous x10 for swing-out legs, adjustable lifting strap, black molded UES, multi-adjustable 
footplates, foot straps, independent knee pads (E1399). 
 
You asked the Plan to pre-approve DME. You say that the requested items would allow you to have a much 
safer way of coming to a standing position as the strap would be behind you in the wheelchair and gradually 
raise you to a standing position. It is a medical necessity in your situation. Moreover, your physical status will 
decline more rapidly if you are no longer able to stand, even though for only 30 minutes several times weekly. 
The Plan denied your request. The Plan says the request is not a covered benefit because the requested items 
are convenience items and not primarily medical in nature; specifically, this requested item has a tray/table 
feature that is not primary medical in nature. 
 
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 a combination sit to stand frame/table system, any size 
including pediatric, with seat lift feature, with or without wheels (E0637) and durable medical equipment 
(DME), miscellaneous x10 for swing-out legs, adjustable lifting strap, black molded UES, multi-adjustable 
footplates, foot straps, independent knee pads (E1399).