Persius/hicric huggingface dataset:
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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the LTACH 
admission. 
 
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's needs are currently being met at a short-term acute hospital. Lateral 
transfer to a LTACH would not provide any benefit. The enrollee can continue care in their current setting until 
stable for transfer to 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 CGM.  
You asked the Plan to pre-approve a CGM. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of CGMs and related supplies have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. 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 G7 CGM.
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 requires 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oncologist office visit to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an oncologist office visit. You say that you want to continue seeing the 
OON provider. The Plan denied your request. The Plan says rules for coverage for OON services have not been 
met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an oncologist office visit to be provided by an out-of-network (OON) provider.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for an IRF admission, but 
skilled therapies at a skilled nursing facility may be approved upon request.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. 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. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right carpal tunnel release surgery (64721). 
 
You asked the Plan to pre-approve the surgical service. You say that you have tingly sensations and numbness 
for the past eight months. You say that it has moved from your fingers to hands and gotten progressively worse 
in the last two months. You also say that you have worn a brace for the last five months with no change. The 
Plan denied your request. The Plan says the records do not show clinical signs and symptoms of carpal tunnel 
syndrome. 
 
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 surgical service. Our reviewer says 
that the requested carpal tunnel release surgery is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the detailed documentation is not fully evident regarding objective examination findings supporting the diagnosis. There are noted negative Tinels, Phalens, and Durkans. The 
reviewer found that you noted that the symptoms do not wake you up at night. Additionally, there is no 
indication you have tried and failed a corticosteroid injection for a right carpal tunnel syndrome. Moreover, 
there are no electrodiagnostic studies provided to corroborate pathology in the exam scenario. 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 right carpal tunnel release 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 surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve right carpal tunnel release surgery (64721).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for continuous glucose monitor (CGM) supplies provided on May 21, 
2023. 
 
You asked the Plan to pay for CGM supplies. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the enrollee claimed to not need a continuous glucose monitor. 
 
The Plan must follow 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 pay for CGM supplies. Our reviewer says that these 
supplies meet criteria for payment. Our physician reviewer found as of April 11, 2023 the enrollee was still 
using insulin and A1C was 8.5%. Therefore, coverage criteria for a CGM are 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 CGM supplies have been met. Therefore, we decided that the Plan has to pay 
for continuous glucose monitor (CGM) supplies provided on May 21, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a home blood pressure monitor.

You asked the Plan to provide coverage for this device. You say that a home blood pressure was medically
necessary. The Plan denied your request. The Plan says the Medicare coverage criteria are not met. Maximus
overturned the Plans denial. The Plan requested a reopen and noted that Maximus did not apply the correct
criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare covers home
blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white
coat hypertension and require ABPM to confirm a diagnosis of hypertension. The medical records do not show
that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of
suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this
case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that
the Plan does not have to provide coverage for a home blood pressure monitor.
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 99285. We decided that the Plan does not have to pay 
for procedure code 93042.  
 
You asked the Plan to pay for the emergency room services provided on March 9, 2022. The Plan says that the 
services are not payable. 
 
We decided that the Plan has to pay for procedure code 99285.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
We find that code 99285 was billed with diagnosis code R10.30, defined as lower abdominal pain, unspecified. 
The medical records provided show that the enrollee presented and was treated for non-specific lower 
abdominal pain. If the side is not identified in the medical record, assign the code for the unspecified side. 
Based on this information, we decided that the Medicare rules for coverage have been met. Therefore, we 
decided that the Plan has to pay for procedure code 99285.  
 
We also decided that the Plan does not have to pay for procedure code 93042. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We looked at the file and the rules. We find that the electrocardiogram, code 93042, is not separately payable. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93042. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option 
(power tilt) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with single power option. You say that this is 
coverage under Medicare. The Plan denied your request. The Plan says the enrollee does not have a medical 
need for either power tilt or power recline. The Plan also says that there is not a medical need to control the 
requested power options through a joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with single power option 
may be covered when certain 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 a Group 3 power wheelchair with single 
power option. Our reviewer says that the requested Group 3 power wheelchair with single power option is not 
medically necessary. Our physician reviewer found there is no face-to-face examination with the treating 
physician in the supplied documentation which confirms that the enrollee is high risk for skin breakdown. The 
reviewer found that the records from the physician do not document the enrollee performs bladder self-
catheterization or that the enrollee has increased muscle tone or spasticity to meet criteria for the power tilt 
and/or recline and thus the single power option base. Therefore, the reviewer found that the requested Group 3 
power wheelchair with multiple power options is not medically reasonable or necessary. As the requested 
wheelchair base does not meet Medicare coverage criteria, the requested accessories are not covered. 
 
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 Group 3 power wheelchair with single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single 
power option (power tilt) and accessories.
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 necessary. The Plan denied your request. 
The Plan says IRF care is not reasonable and 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 needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical records support 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 patient 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal knee-shin system, single axis, fluid 
swing and stance phase control (L5828), an endoskeletal, knee-shin system, stance flexion feature (L5845), an 
addition to endoskeletal knee-shin system, fluid stance extension (L5848), an addition to lower extremity 
prosthesis, endoskeletal knee-shin system, microprocessor control feature (L5856), and an all-lower extremity 
prosthesis, flex-walk system or equal (L5981). 
 
 You asked the Plan to pre-approve prosthetics. You say that the enrollee experienced a change in condition 
with weight gain and maturation of residual limb causing ill fit of the previous prosthetic system. This device 
cannot be modified to achieve the needed fit and function. The Plan denied your request. The Plan says the 
request for a K3 foot does not meet Medicare criteria as reasonable and 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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested items exceed the enrollee's medical needs as Medicare does not pay for any items 
or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member. The documentation does not support that the enrollee is a K3 
ambulator given her significant comorbidities and wheelchair use. The treating medical provider notes do not 
support that the enrollee is a K3 ambulator or that the enrollee requires a mechanical knee and mechanical foot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an endoskeletal knee-shin system, single axis, fluid swing and stance phase control 
(L5828), an endoskeletal, knee-shin system, stance flexion feature (L5845), an addition to endoskeletal knee-
shin system, fluid stance extension (L5848), an addition to lower extremity prosthesis, endoskeletal knee-shin 
system, microprocessor control feature (L5856), and an all-lower extremity prosthesis, flex-walk system or 
equal (L5981).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that due to mitigating factors, the treatment is necessary. 
The Plan denied your request. The Plan says there is not enough evidence that this type of radiation therapy 
guidance is needed or effective for the enrollee's skin cancer. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found usually, IGRT is used when critical structures are abutting or in close proximity to the target 
that is being treated to high doses. This situation does not apply to this enrollee for which the target lesion can 
be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT 
unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not unreasonable to offer 
but not necessary. The device itself is Food and Drug Administration (FDA) approved for use with ultrasound 
though that in and of itself does not mean that daily imaging is necessary but simply that the device was 
designed to incorporate this functionality. The decision is unfavorable for IGRT. Billing for daily IGRT would 
not be "furnished in accordance with accepted standards of medical practice". 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image Guided Radiation Therapy (IGRT) (G6001).