Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs more aggressive therapy instead 
of being discharged home. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee's needs can be met 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited appeal for the denial 
of an IRF admission. You say the enrollee meets full inpatient acute rehabilitation criteria. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81599 for date of service December 1, 2022. 
 
You asked the Plan to pay for procedure code 81599. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 81599 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 81599 for date 
of service December 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676). 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the pneumatic compression device is not covered by 
Medicare to prevent deep vein thrombosis during surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0676).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided to the enrollee on January 7, 2022.
You asked the Plan to pay for ambulance services. You say that the medical records submitted support this service. The Plan denied your request. The Plan says that ambulance services used for the transportation of a hospital inpatient to another facility for diagnostic tests or special treatment is considered part of the inpatient admission, and not separately payable.
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital the movement of the patient is considered "patient transportation" and is covered as an inpatient hospital service.
We looked at the file and Medicare rules. The file indicates the enrollee was inpatient when the ambulance transport was provided. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services provided to the enrollee on January 7, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care provided from November 1, 2022, through November 29, 2022.
You asked the Plan to waive the copayment for the SNF care. You say that you disagree with the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly.
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 $188 copayment for days 21-100 of SNF care. You have been asked to pay $2,398.76 copayment for the SNF care. This item/service falls within the days 21-100 of SNF care benefit category. The Plan provide documentation confirming you were in a SNF from September 28, 2022, through October 27, 2022.
This means you were already into days 21-100 of SNF care when you were admitted to the SNF on November 1, 2022. This means that you have been asked to pay less than 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 the copayment for the skilled nursing facility (SNF) care provided from November 1, 2022, through November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the Axio transcutaneous electrical nerve stimulation (TENS)/neuromuscular and muscular electrical stimulation (NMES) device durable medical equipment for the enrollee.
You asked the Plan to provide coverage for this equipment . You say that this equipment is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for both the Axio transcutaneous electrical nerve stimulation (TENS)/neuromuscular and muscular electrical stimulation (NMES) device. The Maxims Physician Reviewer determined that the requested item is considered medically reasonable and necessary in this case. The reviewer found the enrollee has had Epidural steroid injections, as well as Rhizotomy and Ablation. He takes Oxycodone and Fentanyl for pain. He had a TENS and NMES trial with 50% pain relief for 6 months.
The requested a reopen and stated there is no specific Medicare guidance to address the use of the combined product. Per the FDA report, the device is not approved as a combination product. The medical records show the enrollee suffered a spinal cord injury (SCI) in 2018. He has injury at the C5-C7 levels, with complete quadriplegia. The enrollee has chronic pain due to trauma, and consistently experiences 8-10/10 pain levels. He also has muscle weakness and atrophy, and chronic adhesive arachnoiditis. The enrollee has failed Spinal Cord stimulation trial x 2. He has had Epidural steroid injections, as well as rhizotomy and ablation. He takes Oxycodone and Fentanyl for pain. He had TENS and Neuromuscular stimulation trial with 50% pain relief for 6 months. A request for DME TENS and NMES was made. It is noted that the device is FDA-cleared for pain and atrophy management. The Plan is correct in this case. There is insufficient support in the available medical literature for the use of both the Axio transcutaneous electrical nerve stimulation (TENS)/neuromuscular and muscular electrical stimulation (NMES) device in the setting of spinal cord injury with quadriplegia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this equipment have not been met. Therefore, we decided that the Plan does not have to provide coverage for the Axio transcutaneous electrical nerve stimulation (TENS)/neuromuscular and muscular electrical stimulation (NMES) device durable medical equipment for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS) unit supplies billed to the enrollee for date of service September 18, 2022.
You asked the Plan to pay for this claim. You say that these supplies should be paid by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan provided additional information that shows the provider states the date of service is September 18, 2022. The provider billed for rental of a TENS unit, E0730 RR KX. The delivery ticket is dated August 18, 2021. The packing slip is also dated August 18, 2021.
Additional records were requested but no new packing slip or delivery ticket were found that match September 18, 2022. Review of the claim's history shows this provider has been renting the TENS unit every month to this member since, August 18, 2021. The Medicare guidelines state when a TENS unit is used for the treatment of chronic, intractable pain described in section II, the TENS unit must be used by the beneficiary on a trial basis for a minimum of one month (30 days), but not to exceed two months. The trial period will be paid as a rental. The treating practitioner must monitor the trial period to determine effectiveness of the TENS unit in modulating the pain. For coverage of a purchase, the treating practitioner must determine that the beneficiary is likely to derive significant therapeutic benefit from continuous use of the unit over an extended period. It is also noted that the written order indicates that the Applicable Diagnosis for the use of the TENS Unit is Low Back Pain. The medical records provided do not show these requirements were met during the year long period this unit was billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case this claim could not be paid due to discrepancies with the dates of service and insufficient medical records to support the required utilization and coverage criteria were met. Therefore, we decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS) unit supplies billed to the enrollee for date of service September 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic propulsion tire insert (E2213). 
 
You asked the Plan to pay for the pneumatic propulsion tire insert . 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 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 pay for the pneumatic propulsion tire insert (E2213).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 3, 2022, 
to January 1, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from December 3, 2022, to 
January 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wegovy. 
 
You asked the Plan to pre-approve Wegovy. You say that you disagree with the Plan's denial. 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 Wegovy.   
Benefits for Wegovy 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the RFA. You say that you have lumbar pain upon walking that prevents 
normal exercise. You say that you have been diagnosed with facet arthropathy. You also say that you do not 
have pain radiating down your leg, fractures, tumors or infections. The Plan denied your request. The Plan says 
the RFA is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients when there is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patients pain, 
including but not limited to fracture, tumor, infection, or significant deformity. 
 
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 RFA. Our reviewer says that the 
requested RFA is not medically necessary. Our physician reviewer found the provided documentation supports 
that you have multiple other potential causes for your pain. Therefore, the reviewer found that the requested 
RFA is not medically reasonable or 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bathtub wall rail (E0241) and installation (A9999). 
 
You asked the Plan to pay for the bathtub wall rail and installation. You say that this should be covered. The 
Plan denied your request. The Plan says grab bars are considered a self-help device and are denied as not 
primarily 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 pay for the bathtub wall rail (E0241) and installation (A9999).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve FocalOne high intensity-focused ultrasound (HIFU) (55880).  
 
You asked the Plan to pre-approve FocalOne HIFU. You say that HIFU is the best treatment option for prostate 
ablation. The Plan denied your request. The Plan says that more medical research is needed to support this is 
safe and effective for your condition.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve FocalOne HIFU. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that HIFU treatment of the prostate is neither experimental nor investigational. HIFU was Food 
and Drug Administration (FDA) approved for prostate gland ablation October 9, 2015.  HIFU of the prostate 
has Medicare coverage as of July 1, 2017. More than 100 clinical studies have demonstrated treatment efficacy 
that is comparable to surgery or radiation but with a much lower risk of side effects such as impotence, urinary 
incontinence, and bowel injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of FocalOne HIFU have been met. Therefore, we decided that the Plan has to pre-
approve FocalOne high intensity-focused ultrasound (HIFU) (55880).   
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. You say that the medication is necessary to treat the enrollee's 
eye for a pending surgery. The Plan denied your request. The Plan says there is no record from that shows that 
the enrollee has tried the preferred drug Bevacizumab.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Vabysmo. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the Plan requires a trial of drug 
Bevacizumab before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the plan's required drug would likely be less 
effective or likely to have adverse effects 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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a Barostim neuromuodulation 
system. 
 
You asked the Plan to pre-approve the Barostim implant. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested device 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 Barostim implant. Our reviewer 
says that the requested Barostim implant is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested implant is considered experimental and investigational. The reviewer 
found that there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not be considered medically reasonable and necessary in the enrollee's clinical management. 
Therefore, the reviewer found that the requested Barostim implant is not medically reasonable or 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 Barostim implant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the implantation of a Barostim neuromuodulation system.