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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as you do not meet the clinical 
requirements to be approved. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
item is not medically necessary. Our physician reviewer found that in this case, the record indicates that the 
enrollee has diabetes.  The record provided does not indicate that the enrollee is being treated with insulin or 
has problematic hypoglycemia as defined by the Medicare rules. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
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 enrollee requires an LTACH level of 
care, is stable for discharge and very clearly meets LTACH criteria. The Plan denied your request. The Plan 
says the LTACH services requested do not meet the requirements for approval. 
 
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH would not be clinically advantageous at 
this time and 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 2, 2022, to 
August 30, 2022. 
 
You asked the Plan to pay for home health services. You say that you are out of network and are not required to 
submit an NOA. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 2, 2022. The NOA was not received by the Plan. As more than 30 
days passed since the timely filing date, no payment can be made on this claim. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from August 2, 2022, to August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and an appliance. You say that you are 
requesting reconsideration due to medical necessity. The Plan denied your request. The Plan says the request is 
not medically necessary because the enrollee does not have a four-week trial of regular, daily, multiple-hour 
home usage of the E0650 or E0651. The records show that she used the E0651 only once on April 17, 2023. In 
addition, there was no measurements before and after the trial of conservative therapy documenting failure of 
improvement. Lastly, there was no clinical documentation of truncal edema or edema extending past the 
enrollees legs. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial (63655). 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service 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 a spinal cord stimulator trial. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is no formal psychological or psychiatric examination documented in 
the case record; nor is there documentation of other conservative therapies trialed. 
 
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 spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator trial (63655).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T). 
 
You asked the Plan to pre-approve transurethral waterjet ablation of prostate. You say that transurethral 
waterjet ablation of prostate is a medical necessity for the enrollee. The Plan denied your request. The Plan 
says the requested service 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 transurethral waterjet ablation of 
prostate. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found that the provided medical records do not support that the criteria of 
an IPSS greater than or equal to 12 or of a Qmax of less than or equal to 15 mL/s have 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 transurethral waterjet ablation of prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal epidural steroid injections. 
 
You asked the Plan to pre-approve transforaminal epidural steroid injections. You say that the previous 
injections provided 100% relief for the enrollee. The Plan denied your request. The Plan says that the details 
don't meet Medicare guidelines to show medical necessity. 
 
The Plan follows Medicare rules. Medicare rules state that repeat epidural steroid injections may be covered 
under certain circumstances. 
 
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 transforaminal epidural steroid 
injections. Our reviewer says that the enrollee does not meet criteria for the requested epidural steroid 
injections. Our physician reviewer found Medicare criteria require 90 days of pain relief from the ESI. 
However, the enrollees pain relief appears to have only lasted approximately 45 days. Therefore, this 
requirement was not achieved, and the request is deemed not medically reasonable and 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 transforaminal epidural steroid injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transforaminal epidural steroid injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that this CGM is not medically necessary. The Plan denied 
your request. The Plan says due to a lack of medical records, medically necessity could not be determined. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM. Our reviewer says that a CGM 
is not medically necessary. Our physician reviewer found there is no reason why the enrollee needs a CGM, 
and why fingerstick glucometer would not suffice. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 81335 billed for date of service December 13, 2022. 
 
You asked the Plan to pay for procedure code 81335. You say that this service was medically necessary and 
appropriate. The Plan denied your request. The Plan says that this service was not billed with a diagnosis code 
which supports medical necessity according to Local Coverage Article: Billing and Coding: Molecular 
Pathology and Genetic Testing (A58917). 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Local Coverage Article cited by the Plan does not have 
jurisdiction over the state where these services were performed. The Plan has provided no other reason for 
denial in this case, and their denial is not substantiated by a relevant article or rule. Therefore, we decided that 
the Plan has to pay for procedure code 81335 billed for date of service December 13, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open bilateral sacroiliac joints (SI) joint fusion. 
 
You asked the Plan to pre-approve open bilateral SI joint fusion. You say that the enrollee has had failure for 
non-operative therapy and continues to have pain when walking. The Plan denied your request. The Plan says 
there is no documentation that an external fixator has been tried and it helped the 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 open bilateral SI joint fusion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation is not evident regarding imaging or radiographic 
evidence supporting a sacroiliitis pathology. Multiple other plausible pain generators including at the 
lumbosacral spine are evident. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested open bilateral SI joint fusion (27280), 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 open bilateral SI joint fusion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve open bilateral sacroiliac joints (SI) joint fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Mis sensor. 
 
 
You asked the Plan to pre-approve the Dexcom G6 Mis sensor. You say that the medical records support the 
need for the Dexcom G6 Mis sensor. The Plan denied your request. The Plan says the enrollee is not on insulin 
or does not have documentation of recurrent problematic hypoglycemia. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the Dexcom G6 Mis sensor. Our 
reviewer says that the Dexcom G6  is not medically necessary. Our physician reviewer found criteria for CGM 
coverage require insulin use or low blood glucose sugar. Since there is no documentation of low blood glucose 
sugar or insulin use criteria for CGM use are not met. We are not told why fingerstick glucometer would not 
suffice for 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 Dexcom G6 Mis sensor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G6 Mis sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to the IRF is necessary because the 
enrollee is very weak and needs rehabilitation to build strength in their knee. The Plan denied your request. The 
Plan says the enrollee does not meet the criteria for admission to the 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 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. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the 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 an IRF admission and services.
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 if the enrollee does not get this rehabilitation she will 
decline. 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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical or occupational therapy 
at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement, however, the documentation does not 
support that she would meet criteria for admission to an acute IRF. The enrollee can receive further services 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for  a Group 3 Power wheelchair and accessories (codes K0861, E0953, E0955, E0956, E0957, E0957, E0960, E1007, E1012, E1028, E2377, E2620, E2624, K0108 and E2300).

You asked the Plan to provide coverage for  the requested power wheelchair and accessories. You say that at the time of the appeal, the requested equipment was medically necessary.  The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the requested wheelchair is K0861 is a power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds. The records show you do not have a medical need for the Multiple Power Options included with this type of power wheelchair. There must be medical need for a ventilator or for two power options: power tilt and power recline. The documentation does not show that you are a high risk for development of skin ulcers. The requested power tilt and power recline exceeds your need in the home and are not considered reasonable and necessary per Medicare criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for the power wheelchair and accessories requested. Based on the medical records provided, there is insufficient information provided to show you meet all of those criteria. Therefore, we decided that the Plan does not have to provide coverage for  a Group 3 Power wheelchair and accessories (codes K0861, E0953, E0955, E0956, E0957, E0957, E0960, E1007, E1012, E1028, E2377, E2620, E2624, K0108 and E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided under code 99497 billed to the enrollee for date of service August 21, 2022.

You asked the Plan to pay for these services. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated the records needed for codes 99233 and 99291 we received and rerouted to be reprocessed. As those codes were for dates of service other than August 21, 2022, they did not apply to this case. 
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, we have confirmed that code 99497 is a column II code to column I code 99291. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for  code 99497 billed to the enrollee for date of service August 21, 2022.