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 for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee does not require extended LTAC level 
hospitalization greater than 25 days. 
 
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. The enrollee 
is receiving appropriate care at the present acute care hospital and when considered medically stable by the 
treating team may be an appropriate candidate for care at a less intense level. There are no services available at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 
services. 
 
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 for the enrollee.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee is not safe to transfer to an acute inpatient rehabilitation. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. The documentation does not support that the enrollee is reasonably expected to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heart transplant (33945). 
 
You asked the Plan to pre-approve a heart transplant. 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 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 heart transplant. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the records the enrollee has not demonstrated at least 6 months free of 
nicotine consumption and does not have compliance with home cardiac monitoring or alcohol abstinence. The 
enrollee's noncompliance with nicotine for at least 6 months and noncompliance with cardiac home monitoring 
place him at significantly increased risk of transplant organ failure 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 a heart transplant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a heart transplant (33945).
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you do not require IRF care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require 
intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as 
physical and occupational therapy but the documentation does not support that his functional level requires an 
intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition 
does not meet Medicare criteria for IRF 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: Favorable

 
We decided that the Plan has to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says that therapy needs can be met at a lower level of care in the subacute nursing 
facility for therapy. 
 
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. A review of the case file shows that plan had access to relevant medical records 
for this case. These medical records were not sent to MAXIMUS. The plan has not substantiated their denial. 
Therefore, we decided that the Plan has to pre-approve admission to an inpatient rehabilitation facility (IRF).  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve the Freestyle Libre 14 day sensor kit 
 
You asked the Plan to pre-approve the kit. You say that this is medically necessary. The Plan denied your 
request. The Plan says that in order for this to be covered, you must be using more than three insulin shots per 
day, or be on an insulin pump. 
 
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. The plan did not provide any medical records. We can't determine if their denial 
reason is valid without any medical records. The plan did not substantiate their denial. Therefore, we decided 
that the Plan has to pre-approve the Freestyle Libre 14 day sensor kit 
  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint (SI) lateral nerve branch blocks. 
 
You asked the Plan to pre-approve the SI joint nerve blocks. You say that it is felt that this should be covered. 
The Plan denied your request. The Plan says the enrollee has exceeded the number of facet joint injections 
allowed in a 12 month period. 
 
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 SI joint nerve blocks. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 61-year-old woman with a history of sacroiliitis and radiculopathy. 
Per the documentation she has had numerous prior facet injections, MBBB, and RFA procedures. Her provider 
has requested SI lateral branch blocks. The medical literature regarding the use of SI lateral branch blocks in 
patients with back, buttock, and hip pain is limited. It has not been sufficiently demonstrated that SI lateral 
branch blocks are medically reasonable and necessary, and are expected to be safe and effective in this case. 
 
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 SI joint nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac joint (SI) lateral nerve branch blocks.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 20, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for myocardial perfusion imaging. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the denial of payment for this service is correct, because this 
provider is out-of-network with the Plan and the referring physician is also out-of-network with the Plan. 
 
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 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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on December 20, 
2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computerized ophthalmic diagnostic imaging (J0178) 
provided January 15, 2020. 
 
You asked the Plan to pay for computerized ophthalmic diagnostic imaging. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the records provided do not support the 
services billed. 
 
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 find that CPT code J0178 is not supported in the medical record. Specifically, the claim includes the RT 
anatomical modifier indicating the service was performed on the right eye. However, the records provided 
show the service was performed on the left eye. Based on this information, we decided that Medicare rules for 
coverage of computerized ophthalmic diagnostic imaging have not been met. Therefore, we decided that the 
Plan does not have to pay for computerized ophthalmic diagnostic imaging (J0178) provided January 15, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on April 1, 2019. 
 
You asked the Plan to pay for drug tests. You say that you conducted the tests ordered by the treating 
physician, who deemed service to be medically necessary. The Plan denied your request. The Plan says that the 
denial of payment for this testing is correct, because the documentation does not show why this testing was 
necessary. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for these 
services is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for drug testing 
provided on April 1, 2019.  
 
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 pay for the electric hospital bed with mattress and a lightweight 
transport wheelchair provided April 20, 2020. 
 
You asked the Plan to pay for the durable medical equipment items. You say that the items were medically 
necessary. The Plan denied your request. The Plan says these items must be rented and are not covered when 
obtained from out-of-network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that durable medical equipment of this nature must be rented from in-network providers. 
 
The requested provider in this case was not a network provider with the Plan. The Plan has network providers 
available who can provide the items at issue in this appeal. The Plan did not pre-approve the items at issue. We 
found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does 
not have to pay for the electric hospital bed with mattress and a lightweight transport wheelchair provided April 
20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 2, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on March 2, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for doctor care provided to the enrollee on February 6, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the services were not urgent or emergent. 
 
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 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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for doctor care provided to the enrollee on February 6, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 20, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules also say that a physician order is not required to be signed, however, the physician must clearly 
document, in the medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Furthermore, we find that payment for the lab services is not supported in the medical record. We find that the 
issue of intent is not clear. There are no medical records in the case file in regards to the physician?s intent that 
the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on December 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on April 22, 2020 and 
April 23, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were in the hospital and a doctor 
prescribed you the medications. You also say that you were unable to have someone get the medications from 
your home. The Plan denied your request. The Plan says the self-administered drugs are not covered under Part 
B. 
 
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 pay for the self-administered drugs 
provided on April 22, 2020 and April 23, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on November 19, 2019.

You asked the Plan to waive the copayment for lab work. You say that this was a routine PSA test. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for outpatient diagnostic tests/laboratory tests. 

You have been asked to pay $11.55 which is less than your copayment amount of $15 for lab work. The services that were provided were not routine; therefore, the correct copayment has been applied. Lab work falls within the outpatient diagnostic tests/laboratory tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 27, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 27, 
2019.