Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the enrollee's condition is urgent, and 
the surgery is needed very soon. The Plan denied your request. The Plan says that the information provided 
does not support the medical necessity of the requested service. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are covered when certain 
clinical criteria have been met and when medically reasonable and necessary.  
 
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. Our reviewer 
says that the criteria for coverage have been met. Our physician reviewer found the enrollee had an L1-L5 
fusion in February of 2015. She continues to have low back pain with radicular symptoms. She saw a 
neurosurgeon who did not think she was a further surgical candidate. She has failed Epidural steroid injections, 
physical therapy, NSAIDs, Morphine and Gabapentin. She was cleared by a psychologist for a spinal cord 
stimulator trial. There are no more interventions appropriate for the enrollee. A spinal cord stimulator is 
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 a spinal cord stimulator have been met. Therefore, we decided that the Plan has 
to pre-approve a spinal cord stimulator.  
 
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 pay additionally for the vision services provided on August 18, 2020. 
 
You asked the Plan to pay additionally for the vision services. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says they paid the $100 supplemental vision 
benefit allowance and you are responsible for the remaining cost. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
 
 
 
 
 
 
 
 
We looked at the file and the Plan's rules. The Plan?s contract covers up to $100 for supplemental vision 
services. The file shows that the Plan paid the $100 supplemental vision benefit allowance and you are 
responsible for the remaining cost. Therefore, we decided that the Plan does not have to pay additionally for the 
vision services provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the telemedicine visit (99204 and 99354). You say that you would like 
reconsideration because prior authorization is not required due to COVID-19. The Plan denied your request. 
The Plan says these services were not urgent, emergent or 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 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 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 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 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 medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services 
but does not require an intensive inpatient rehabilitation therapy program. There is concern that the enrollee 
will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in 
an inpatient rehabilitation facility due to her functional limitations. Care at the skilled nursing facility level 
appears to be more appropriate 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 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 pay for the acute inpatient hospital care provided from June 10, 2020, to June 
12, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the patient is a 49-year-old female who presented to the emergency department with acute 
psychosis. She was non-compliant with medications. She was admitted with acute psychosis related to bipolar 
disorder, generalized anxiety disorder, hypomagnesemia, vitamin D deficiency, and a urinary tract infection 
with leukocytosis. The clinical global impression score was 5 for markedly ill. Based on the severity of the 
patient's presentation and the history of non-compliance, it was most safe to admit to the hospital to stabilize 
her medically prior to discharge which was expected to require hospital care that would cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from June 10, 2020, to June 12, 2020.  
 
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 pay for panniculectomy provided to the enrollee on July 1, 2020. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 services. Our reviewer says that the 
services at issue in this case are not medically reasonable or necessary. Our reviewer found adequate medical 
records were not provided for review. An examination, photographs or operative reports were not provided for 
review. There is insufficient medical documentation to support that an upper and lower abdominal 
panniculectomy was medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for panniculectomy provided to the enrollee on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of x-rays provided on August 
25, 2020 coded as D0210. 
 
You asked the Plan to pay for the intraoral complete series. You say that you were not told that you were 
getting any noncovered services. The Plan denied your request. The Plan says you were provided with a 
complete series of x-rays. Your plan only covers panoramic x-rays. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral complete series of x-rays provided on August 25, 2020 coded as D0210.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Posaconazole Dr. 
 
You asked the Plan to pre-approve Posaconazole Dr. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Posaconazole Dr.  
 
Benefits for Posaconazole Dr 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography services provided on June 19, 2020. 
 
You asked the Plan to pay for the computed tomography services. You say that the right to recover for services 
provided to eligible beneficiaries enrolled in the Plan by the IHS, Tribes, or Tribal organizations is not 
extinguished by specific plan requirements, such as network participation and/or direct payment to the 
insureds. The Plan denied your request. The Plan says the claim was not billed in accordance with CMS 
guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that all charges, except for therapies, telehealth 
originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance 
services are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient). 
 
We looked at the file and Medicare rules. The services in dispute were supplied by an HIS provider. The claim 
does not show that the services billed were combined and reported under revenue code 0510 on TOB 13X. 
Based on this information, we decided that Medicare rules for coverage of the computed tomography services 
have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography services 
provided on June 19, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography angiography (CTA) scan of the chest and 
CTA of the abdomen and pelvis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically 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. 
 
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 states that the services are not medically necessary; however, there are 
no medical records to review. MAXIMUS requested medical records from the Plan but none were received. 
Without medical records documenting the enrollee's current condition, a determination based on medical 
necessity is not supported. Therefore, we decided that the Plan has to pre-approve a computed tomography 
angiography (CTA) scan of the chest and CTA of the abdomen and pelvis.  
 
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: 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 will continue to have 
unplanned readmission if admitted to lower level of care. The Plan denied your request. The Plan says this is 
not medically necessary because your records show you have completed your full course in the hospital and 
still have unstable conditions which have not been addressed. 
 
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 is no documentation provided necessitating admission to a LTACH. The 
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute 
care hospital. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where she is currently receiving care. 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. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
and able to be furnished safely and effectively only on an inpatient basis. 
 
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 Paclitaxel for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this drug is not being requested for a medically-accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the review indicates 
that there is no compendia support for the combination of Paclitaxel and liposomal doxorubicin, including in a 
sequential manner. To date, it is not yet known whether Paclitaxel is more effective when given with 
Carboplatin or Ifosfamide in treating patients with uterine, ovarian, fallopian tube, or peritoneal cavity cancer. 
The review has determined that the documentation does not support that the Paclitaxel is medically reasonable 
and necessary for the enrollee. The documentation does not support that the Paclitaxel is safe and effective for 
the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Paclitaxel for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular genetic testing (81407 and 81408) provided on 
June 15, 2020. 
 
You asked the Plan to pay for the molecular genetic testing. You say that you would like reconsideration 
because these services are covered by Medicare. The Plan denied your request. The Plan says Medicare does 
not cover Cardiovascular Risk Assessment except for the basic lipid panel. 
 
The Plan follows Medicare rules. Medicare rules say that with few exceptions, screening tests are excluded 
from coverage. 
 
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 molecular genetic testing. Our reviewer 
says that the member has no symptoms or signs of cardiovascular disease and no lipid profiles to suggest a 
familal hyperlipdemia syndrome. Our physician reviewer found the member has not had a standard 
cardiovascular risk assessment and consideration of treatment for hyperlipidemia based on these published 
ACC/AHA guidelines using a standard lipid profile and clinical risk factors. There is not any medically 
necessary reason for this genetic testing for cardiovascular risk 
 
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 molecular genetic testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the molecular genetic testing (81407 and 81408) provided on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on August 3, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the physician services. You say that the doctor assumed that authorization was 
obtained. The Plan denied your request. The Plan says you did not request prior authorization. 
 
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 service 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 physician services provided on August 3, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided March 18, 2019. 
 
You asked the Plan to pay for the dental services. You say that you believe you are being overcharged and 
would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this 
claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental services was not filed until September 9, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the dental services provided March 18, 2019.
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 medically necessary. The Plan denied 
your request. The Plan says you do not meet Medicare criteria for coverage of 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. Our 
physician reviewer found you are not shown to be able to perform fifteen hours per week of rehabilitative 
services with regular physician evaluation. Your care needs can be met 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 inpatient rehabilitation facility (IRF) admission and services.