Persius/hicric huggingface dataset:
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 because the enrollee needs 
rehabilitation. The Plan denied your request. The Plan says that the enrollee could receive care in another 
setting.  
 
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. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair with multiple 
power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (K0862) and additional items 
and accessories (E0973, E1007, E2377, E2311, E2313, E1028, K0040, E0955, E2363, E1012, E0978, E2341, 
E2342, E0956, E0950, E0953, E0954, K0108, E2609, E2617). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you would like this 
medically necessary device to be approved for the enrollee, as their mobility, postural, and medical outcomes 
depend on it. The Plan denied your request. The Plan says the enrollee does not have medical need for the 
requested Group 3 power wheelchair. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a left hemiparesis. The record is a form indicating 
medical need for the wheelchair. Braden scale is scored as moderate risk for skin injury. Per L33789, the 
enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. Therefore, the enrollee does not meet criteria for approval. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair with multiple power option, 
sling/solid seat/back, patient weight capacity 301 to 450 pounds (K0862) and additional items and accessories 
(E0973, E1007, E2377, E2311, E2313, E1028, K0040, E0955, E2363, E1012, E0978, E2341, E2342, E0956, 
E0950, E0953, E0954, K0108, E2609, E2617).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the current facility is unable to meet the 
enrollee's complex needs. The Plan denied your request. The Plan says the LTACH services are not medically 
necessary. 
 
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 pending MRI report will help the enrollee determine whether hospice might 
be a better option. It would be appropriate to defer the LTACH transfer until that information is available. It is 
unclear if their seizures are still active or if they are managed with the current medications.  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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing, for 15-21 drug classes (G0482) 
provided January 17, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that the document supports for more than 15 drug 
classes. As per medical record and CMS policy guidelines, the billed diagnosis is appropriate. The Plan denied 
your request. The Plan says under Medicare rules, the number of definitive urine drug classes requested 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 pay for the laboratory testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic neck and back pain and is taking oxycodone and Alprazolam for pain. 
There is no documentation of early refills, self-escalation or diversion. There was no indication for definitive 
drug testing. The request was not medically necessary and reasonable. 
 
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 laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for definitive drug testing, for 15-21 drug classes (G0482) provided January 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance supplies billed for date of service February 
18, 2023. 
 
You asked the Plan to pay for the ambulance supplies. You say that the trip is not related to a work injury. The 
Plan denied your request. The Plan says the supplies are included in the base payment rate. 
 
The file shows that disposable linens (A0382), pulse oximetry (A0999), and a nasal cannula (A4615) were 
provided. The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part 
of the general ambulance service and payment for them is included in the payment rate for the transport. 
Therefore, we decided that the Plan does not have to pay for the ambulance supplies billed for date of service 
February 18, 2023.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical, and rehabilitation can be provided in 
a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. There is documentation that there is a reasonable expectation that this patient will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF, but the 
services required can be provided at a lower 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: 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 IRF is medically necessary. The 
Plan denied your request. The Plan says the notes do not show that your care specifically require the 
involvement of a doctor in the field of Rehabilitation Medicine; the notes do not show that you have complex 
care needs that require a coordinated team approach; the notes do not show that you must have an intensive 
therapy program (3 hours a day, at least 5 days a week) in order to improve self-care functioning.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical therapy and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
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: 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 benefit significantly from IRF 
services. The Plan denied your request. The Plan says the enrollee does not meet the requirements 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 enrollees 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. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation program provided in an IRF. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. The Plan denied your request. The Plan says Medicare
coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted
that Maximus did not apply the correct criteria. The Plan noted that the enrollee is status post below the knee
amputation. However, the records do not show the enrollee required daily skilled therapy and daily skilled
nursing services at an IRF level of care.

The Plan is correct in this case. 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.
Based on the medical records provided, while IRF admission may have been considered beneficial, the enrollee
did not meet the criteria required for coverage at the time of the appeal. Therefore, we decided that the Plan
does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the
enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure addresses vertebrogenic 
pain by addressing a gap in the treatment algorithm for those suffering from chronic low back pain. You also 
say that the enrollee has tried and failed conservative treatment without relief. 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 Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no magnetic resonance imaging (MRI) showing only Modic changes without facet degenerative joint disease or stenosis. The reviewer found that the provided records do not show 
a clear cause of the enrollee's pain. Therefore, the reviewer found that the requested Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve the Signatera genetic testing (0340U).  
 
You asked the Plan to pre-approve the genetic testing. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says that based on Medicare 
guidelines, the genetic test called Signatera (0340U) requested does not meet the requirements for approval. 
 
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 the genetic testing. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the records show the enrollee's breast cancer is Stage IV estrogen receptors 
positive/progesterone receptors positive (ER/PR+) and human epidermal growth factor receptor 2 (HER2). 
Breast cancer was initially diagnosed in 1989 and treated with lumpectomy and radiation. In 2012 found with 
first recurrence leading to bilateral mastectomy with reconstruction and started on endocrine therapy. 
Recurrence chest wall requiring resection of the recurrence in the skin and chest wall in July 2021. The enrollee 
then had progression with bone metastasis in March 2023 then placed on Arimidex and Zometa. There was 
another progression requiring change to Fasolodex and Ibrance. The enrollee had a positron emission 
tomography (PET) scan which showed progression of extensive metastatic disease. The records support that all 
of the criteria has been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have been met. Therefore, we decided that the Plan has to 
pre-approve the Signatera genetic testing (0340U).   
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine culture testing. 
 
You asked the Plan to pay for 87086. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says 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 87086 is culture, bacterial; quantitative colony count, 
urine. 
 
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 87086. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found for code 87086, the lab analyst or microbiologist cultures the 
submitted urine specimen, typically a clean catch or catheterized collection, and if growth is present reports the quantitative colony count result. This procedure was not documented and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87086 have not been met. Therefore, we decided that the Plan does not have to 
pay for urine culture testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair with single 
power option, sling/solid seat/back, patient weight 301 to 450 pounds (K0858) and additional items and 
accessories (E0955, E0995, E1002, E1028, E2363, E2608, E2621, K0108). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you would like this 
request to be favorable for all items so that the enrollee can live at home safely and securely with significant 
reduction in hospitalization due to injury. The Plan denied your request. The Plan says the enrollee does not 
have a medical need for a single power option (power tilt) included with a K0858 Group 3 power wheelchair. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee had a stroke many years ago. She is able to stand and walk 
although the distance she is able to walk is not clear. Physician states she can walk 300 feet. Physical therapy 
scores her much lower. She has intact skin and does not use a catheter. Per L33789, the enrollee does not have 
high risk for skin breakdown, use a catheter intermittently, have spasticity or require an alternative means of 
managing power drive. The enrollee does not meet criteria for approval. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair with single power option, 
sling/solid seat/back, patient weight 301 to 450 pounds (K0858) and additional items and accessories (E0955, 
E0995, E1002, E1028, E2363, E2608, E2621, K0108).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ofev. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary for the enrollee. 
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 Ofev.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.