Persius/hicric huggingface dataset:
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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. Our 
physician reviewer found based on the documentation provided, the health plan's denial should be upheld. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen (15) hours per week of rehabilitative services and regular physician evaluation. The enrollee's 
care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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: 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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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. Our 
physician reviewer found based on review of the medical records, the patient does not meet the CMS coverage 
criteria for an IRF admission. The patient is generally medically stable after a fall with Debility with no 
evidence of medical or nursing needs for an IRF. There is no evidence of medical issues that require 
monitoring by an inpatient rehab physician three (3) times a week. The documentation does not support that 
there is a need for an intensive therapy program with 3 hours a day an interdisciplinary approach to rehab care. 
The IRF admission is not medically necessary for this patient, and also does not meet the CMS coverage 
criteria due to lack of medical intensity. The patient's rehab needs can be safely and effectively met in an 
alternate, less intense setting such as in a skilled nursing facility (SNF). 
 
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: 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. The Plan denied your request. The Plan says the services are not 
medically necessary, and the enrollee does not meet the 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 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. Our 
physician reviewer found the enrollee does not meet the CMS coverage criteria for an IRF admission. Our 
reviewer found that the documentation does not support that there is a need for an intensive therapy program 
with 3 hours a day at current level of function and an interdisciplinary approach to rehab care. Our physician 
reviewer also found that the enrollee's rehab needs can be safely and effectively met in an alternate, less intense 
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 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: 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 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. 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. Therefore, this request for LTACH services will be considered not 
medically necessary at this time. Transfer to a lower level of care may be considered when treatment has 
completed and clinical stability is noted. 
 
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 pre-approve 3 skilled nursing visits, 12 physical therapy (PT) visits, 
and 12 home health aide visits. 
 
You asked the Plan to pre-approve 3 skilled nursing visits, 12 PT visits, and 12 home health aide visits. 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. 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 3 skilled nursing visits, 12 PT visits, 
and 12 home health aide visits. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found you do not have documented skilled nursing needs. You do not have documented skilled 
therapy needs. The assistance of a home health aide (HHA) is not medically necessary. Your care needs are 
custodial and can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 skilled nursing visits, 12 PT visits, and 12 home health aide visits have not 
been met. Therefore, we decided that the Plan does not have to pre-approve 3 skilled nursing visits, 12 physical 
therapy (PT) visits, and 12 home health aide visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotic management and/or training services provided 
on January 13, 2020 billed with two units of code 97763. 
 
You asked the Plan to pay for the orthotic training services. You say that this claim was correctly coded to 
describe the services rendered and should be paid as billed. The Plan denied your request. The Plan says the 
documentation does not support that two units of 97763 were provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97763 is orthotic(s)/prosthetic(s) management and/or 
training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) 
encounter, each 15 minutes. 

We find that two units of CPT code 97763 are not supported in the medical record. Specifically, the record 
documents 16 minutes were provided for this service. One unit of a 15-minute increment code is used to report 
from 8 to 22 minutes of care. Since less than 22 minutes of services were provided, only one unit of this code is 
supported. Based on this information, we decided that Medicare rules for coverage of the orthotic training 
services have not been met. Therefore, we decided that the Plan does not have to pay for the orthotic 
management and/or training services provided on January 13, 2020 billed with two units of code 97763.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on February 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on February 17, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intubation procedure provided on February 22, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
services cannot be supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The records provided shows the service date as February 23, 2020. 
However, the claim indicates the services were provided on February 22, 2020. We find that CPT code 31500 
is not supported in the medical record.  Based on this information, we decided that Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the intubation procedure 
provided on February 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the posterior interspinous spacer procedure for the 
enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer device is experimental. More research is needed to show safety and efficacy. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the posterior interspinous spacer procedure for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) 
care provided from January 8, 2020, through February 7, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $0 
copayment per day, for days 1-20 and a $164 copayment per day, for days 21-100, for inpatient skilled nursing 
facility care.  
 
You have been asked to pay a $1,640 copayment ($164 copayment x 10 days) for the inpatient skilled nursing 
facility care provided. 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 the inpatient skilled nursing 
facility (SNF) care provided from January 8, 2020, through February 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator provided on March 14, 
2020. 
 
You asked the Plan to pay for the provided item. You say that you were advised you would be reimbursed for 
the oxygen concentrator. The Plan denied your request. The Plan says coverage is only considered when it is 
rented. 
 
The Plan must follow Medicare rules. Medicare rules say that contractors may not pay for oxygen equipment 
that is purchased. 
 
We looked at the file and the rules. Payment is not made for the purchase of oxygen equipment. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the portable oxygen concentrator provided on March 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care received from April 26 to May 24, 2020. 
 
You asked the Plan to pay for SNF care. You say that the enrollee needed SNF care. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that as of April 25, 2020, the enrollee did not 
require any skilled nursing or rehab services on a daily basis. The enrollee was not expected to make 
measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or activities of daily living. The enrollee did not require skilled therapy to establish 
a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled 
services on an inpatient basis at a SNF level of care during the period of care under review. The enrollee's 
function was at baseline and the enrollee did not have any further skilled nursing needs. As of April 25, 2020, 
the enrollee required custodial 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care received from April 26 to May 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post stabilization care provided on March 7, 2020, through March 9, 2020.

You asked the Plan to pay for the post stabilization care. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized by 10:21am on March 8, 2020 and subsequent care was post stabilization care, not approved in compliance with the health plan's authorization procedures.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the post stabilization care. Our reviewer says that the post-stabilization care services at the out-of-network facility after 10:21 am on March 8, 2020 to 11:52 pm on March 9. 2020 were not medically necessary. Our physician reviewer found the treating physician did not document (in the physician notes, on a form, or in an order) that the member was not stable for transfer on any dates of service.

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 post stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for post stabilization care provided on March 7, 2020, through March 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic screening testing provided on May 15, 2020. 
 
You asked the Plan to pay for genetic tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because this testing is not 
a Medicare benefit for the diagnoses listed and was performed for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, genetic tests, were requested for screening purposes. Medicare does not cover 
these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic 
screening testing provided on May 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology examination of tissue using a microscope 
(88305) provided on November 27, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the pathology examination of tissue using a microscope. You say that you did not 
see the patient and are considered a "Hidden/Blind Provider." The Plan denied your request. The Plan says 
prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly 
denied. 
 
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 pathology examination of tissue using a 
microscope (88305) provided on November 27, 2019, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits and related services (99213, 99214, 20610, 
73030, J1100) provided on May 4, 2020 to June 25, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON office visits and related services. You say that this services were approved. 
The Plan denied your request. The Plan says these services were not authorized. 
 
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 office visits and related services (99213, 
99214, 20610, 73030, J1100) provided on May 4, 2020 to June 25, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0427) received 
on June 5, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the service provided was 
bad. The Plan denied your request. The Plan says you were charged this cost sharing correctly. 
 
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 $265 
copayment for each date of service. You had 1 ambulance trip on June 5, 2020. The Plan charged you $265 for 
these services. 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 the ambulance services (A0427) received 
on June 5, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.