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

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection. You say that when one power seating 
function/actuator/motor is provided on a power wheelchair, one unit of E2311 is allowed. The Plan denied your 
request. The Plan says although two power features are requested for this wheelchair (tilt and elevating leg 
rests), there is not a medical need to control these power options through the joystick. 
 
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 an electronic connection. 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 residual weakness from a stroke but is able to eat and dress 
independently. Our reviewer also found that the enrollee has adequate upper body strength to manage standard 
power drives. 
 
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 electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mohs micrographic surgery (17314, 17313). 
 
You asked the Plan to pre-approve Mohs micrographic surgery. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary because the records show you do not 
have biopsy results with confirmatory diagnosis of cancer. 
 
The Plan follows Medicare rules. Medicare rules say that Mohs micrographic surgery can be covered when 
specific criteria are met. 
 
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 Mohs micrographic surgery. Our 
reviewer says that you do not meet criteria for coverage. Our physician reviewer found that the 
histopathological results proving the malignant nature of the tumor need to be provided to be considered for 
coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Mohs micrographic surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Mohs micrographic surgery (17314, 17313).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve negative pressure wound therapy electrical pump, 
stationary or portable (E2402 x5) and wound care set (A6550 x75). 
 
You asked the Plan to pre-approve negative pressure wound therapy electrical pump and wound care set. You 
say that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a NPWT pump and supplies are covered when 
specific criteria are met. 
 
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 negative pressure wound therapy 
electrical pump and wound care set. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the documentation does not support that LCD criteria are fulfilled. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of negative pressure wound therapy electrical pump and wound care set have not 
been met. Therefore, we decided that the Plan does not have to pre-approve negative pressure wound therapy 
electrical pump, stationary or portable (E2402 x5) and wound care set (A6550 x75).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a harness (E2313) and expandable controller (E2377). 
 
You asked the Plan to pre-approve a harness and expandable controller. You say that there is no less costly 
option to manage the enrollee's abnormal tone and complaints of pain than a group 3 power wheelchair. The 
Plan denied your request. The Plan says although there are three approved power options on this wheelchair 
(tilt, recline and elevating leg rests), there is not a medical need to control these power options through the 
joystick. 
 
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 harness and expandable controller. 
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 paraplegia and 5 out of 5 strength in their upper 
extremities. Our reviewer also found that the enrollee has adequate upper body strength to manage standard 
power drives. 
 
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 harness and expandable controller have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a harness (E2313) and expandable controller (E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allograft (20930), arthrodesis (22558), and anterior 
instrumentation (22845). 
 
You asked the Plan to pre-approve an allograft, arthrodesis, and anterior instrumentation. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an allograft, arthrodesis, and anterior 
instrumentation. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found detailed documentation regarding a trial and failure of 
recent, reasonable, comprehensive, less invasive conservative care measures is not evident. On the June 22, 
2023, examination, she noted she was involved in a motor vehicle accident a month prior that caused the pain 
that she was having prior to surgery to return. The documentation does not clearly support any conservative 
measures having been tried after this time. Additionally, the requested procedure is noted to be potentially 
complicated. Her current examination did not corroborate any significant neurological deficits or progression 
of her symptoms from her June 22, 2023, examination to the August 3, 2023, examination. The computed 
tomography (CT) scan noted from June 19, 2023, showed moderate disc narrowing with a 1-millimeter disc 
bulge and mild facet hypertrophy with normal foramina at T12-L1. There is a lack of significant neurological 
deficit, lack of significant pathology on the CT scan to support the request for the surgery with provider 
documented risk of plausible prior and/or potential future surgical complications. There are limited large-scale, 
long-term references showing the safety and efficacy of the requested surgery in this clinical 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 an allograft, arthrodesis, and anterior instrumentation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an allograft (20930), arthrodesis (22558), and 
anterior instrumentation (22845).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.

You asked the Plan to pre-approve home health services. You say that the enrollee has a chronic stable condition without skilled services are not medically necessary. The Plan denied your request. The Plan says the services are not medically necessary. 

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee has chronic stable condition without skilled services are not medically 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for r the WATS Oral Brush CDx Biopsy test (88104, 88305, 88312, 88361) provided on April 11, 2022.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says insufficient records were provided to support the services billed. Maximus overturned the Plans denial for insufficient medical records. The Plan requested a reopen and stated that Plans are not held responsible for records not provided by out of network providers.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of this testing have been met. . Therefore, we decided that the Plan does not have to pay for r the WATS Oral Brush CDx Biopsy test (88104, 88305, 88312, 88361) provided on April 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pomalyst for the enrollee under Medicare Part B.
You asked the Plan to pre-approve the medication. You say that this drug is medically necessary. The Plan denied your request. The Plan says the medication is not covered under Medicare Part B. Maximus upheld the decision and then reopened the decision to give more clarity on the Medical Review. At issue is coverage of Pomalyst (Pomalidomide). The enrollee has a diagnosis of Multiple myeloma not having achieved remission. Velcade, Pomalidomide, and Dexamethasone have been prescribed since February 1, 2023. This is 4th line treatment with a treatment goal of control.
The enrollee's plan does not cover self-administered prescription drugs. For an oral anti-cancer to be covered under Medicare Part B, it must have the same active ingredients as a non-self-administrable anti-cancer chemotherapeutic drug or biological that is covered when furnished incident to a physician's service. Pomalyst does not have the same active ingredient (Pomalidomide) as a non-self-administrable anti-cancer chemotherapeutic drug or biological that is covered when furnished incident to a physician's service.
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 Pomalyst for the enrollee under Medicare Part B.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on September 30, 2022.
You asked the Plan to pay for this testing . You say that this claim should be paid. The Plan denied your request. The Plan says the DEX-Z code billed created a claim error. Maximus overturned the Plans denial. The Plan requested are reopen and submitted a copy of the Diagnostic Exchange Registry which shows DEX Z-Code Z00D5 shows a coverage status of "not covered" for Medicare claims.
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 codes. In this case, this claim was not submitted with a valid DEX-Z code for the services billed. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for periodontal scaling and root planing (D4341) for all four quadrants.
You asked the Plan to provide coverage for these dental services. You say that these dental services are medically necessary. The Plan denied your request. The Plan says the dental records do not establish medical necessity. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for periodontal scaling and root planing (D4341) for all four quadrants. The Maximus Physician Reviewer determined periodontal scaling and root planing was reasonable. The Plan requested a reopen and noted the records did not indicate that 4 or more teeth were affected in each quadrant. The Plan is correct in this case. There is insufficient evidence that 4 or more teeth were affected by significant bone loss and/or radiographic root surface calculus in each quadrant. Medical necessity was not established. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the records provide do not support these services are medically necessary. Therefore, we decided that the Plan does not have to provide coverage for periodontal scaling and root planing (D4341) for all four quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for COVID-19 testing provided for travel purposes on September 3, 2022.
You asked the Plan to pay for this testing. You say that this testing was needed for travel. The Plan denied your request. The Plan says this testing is not covered for travel. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and confirmed this testing was requested for travel.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. This test was provided for travel purposes and was not reasonable and necessary for the diagnosis or treatment of an illness or injury. Therefore, we decided that the Plan does not have to pay for COVID-19 testing provided for travel purposes on September 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on April 10, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time services were provided the enrollee was 
residing in an assisted living facility. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on April 10, 2023.
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 you are requesting reconsideration for 
the denial of an LTACH admission based on medical necessity. The Plan denied your request. The Plan says 
the request for admission to an LTACH is being denied as 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 the enrollee is receiving acute hospital care, and acute care services have not 
been denied. The documentation does not support that the enrollee requires services at the LTACH that are not 
available at the acute care hospital where they are currently receiving care. The requested LTACH services are 
not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: 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 reconsideration as 
the enrollee currently meets IRF admission criteria. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for care in 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 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. 
 
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 you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostatic artery embolization (PAE) (37243).  
 
You asked the Plan to pre-approve the PAE. You say that this service will benefit the enrollee. The Plan denied 
your request. The Plan says there is insufficient evidence to assess the efficacy of prostate artery embolization 
(PAE) relative to laser enucleation of the prostate or prostate urethral lift. The Plan also says more studies are 
needed to show if it can help the enrollee's condition. 
 
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 PAE. Our reviewer says that the 
requested PAE is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the records do not show that the enrollee has severe/intractable prostatic hemorrhage, but rather benign 
prostatic hyperplasia (BPH) with obstruction/retention. The reviewer found that prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic BPH. Very limited studies have 
demonstrated possible short-term safety and efficacy. The most recent AUA guidelines do not recommend this 
procedure outside of a clinical trial setting. Therefore, the reviewer found that the requested PAE 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 PAE have not been met. Therefore, we decided that the Plan does not have 
to pre-approve prostatic artery embolization (PAE) (37243).