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

 
We decided that the Plan does not have to pay for orthoses (L1833, L2397) provided September 10, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied 
your request. The Plan says the documentation does 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 codes L1833, & L2397 are not supported in the medical record. Specifically, the plan record 
shows the enrollee received no billed service from this physician on the date the order was made. There is no 
record of a video or telephonic visit. Based on this information, we decided that Medicare rules for coverage of 
the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for orthoses (L1833, 
L2397) provided September 10, 2020.
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. The Plan denied your request. The Plan says the 
enrollee's needs do not require an LTACH level of care. 
 
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 physician 
reviewer found that the enrollee presented to the emergency room with complaints of fever up to 103, with 
associated lethargy and confusion. He was found to have leukocytosis. His altered mental status is described as 
improving. He does not require wound care or tube feedings. The enrollee is receiving appropriate care at the 
present acute care hospital. He does not require services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. There are no services available at the LTACH that he requires 
that are not available at the health care setting being offered by the health plan. Therefore, the requested 
LTACH services are 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography and nerve conduction studies 
provided on October 26, 2020. 
 
You asked the Plan to pay for needle electromyography (95886) and nerve conduction studies (95911). You 
say that the Plan should pay this claim. The Plan denied your request. The Plan says a corrected claim is 
needed to reflect the correct modifier for the professional component listed on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate Place of Service code.   
 
In this case, code 95886 and 95911 cannot be paid as billed due to an error with the POS code. Medicare billing 
criteria are not met. Therefore, we decided that the Plan does not have to pay for needle electromyography and 
nerve conduction studies provided on October 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen equipment provided by an OON provider.

You asked the Plan to pay for oxygen equipment. You say that you are requesting reimbursement for this item.
The Plan denied your request. The Plan says the denial of payment for this item is correct, because this
provider is out-of-network with the Plan and authorization was not obtained.

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 had network providers
available who could have provided 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 oxygen equipment provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vasectomy (CPT code 55250), for the enrollee. 
 
You asked the Plan to pre-approve the vasectomy. You say that the enrollee decided to avoid further 
pregnancy. The Plan denied your request. The Plan says this procedure is not covered for sterilization. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the vasectomy have not been met. Vasectomy procedures are not 
covered by Medicare if the primary indication for this procedure is sterilization. Review of the records show 
that the requested procedure is for sterilization for this reason it is not covered. Therefore, we decided that the 
Plan does not have to pre-approve the vasectomy (CPT code 55250), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone. 
 
You asked the Plan to pre-approve Oxycodone. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Oxycodone is not covered under the enrollee's Medicare Part B 
benefit. 
 
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 Oxycodone.  
 
Benefits for Oxycodone 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthoses (L2397, L1833) provided September 14, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the items 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 codes L2397, & L1833 are not supported in the medical record. Specifically, plan records 
show no physician service billed for the date the items were ordered. The record does not show that the 
enrollee received a video or telephonic visit by the ordering physician. Based on this information, we decided 
that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does 
not have to pay for orthoses (L2397, L1833) provided September 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that your needs can only be provided at a 
LTACH. The Plan denied your request. The Plan says you do not require daily physician management or 
specialized nursing services only available in an LTACH. 
 
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 evidence that the enrollee requires services that are not currently available. 
As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are 
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 
 
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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care you received 
from September 3, 2020, to September 7, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you feel that this 
charge is a billing error.  You say that when you were in the hospital on a previous occasion, your plan paid for 
that stay 100%. The Plan denied your request. The Plan says you were charged this copayment 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 $285 
copayment per day for days 1-7 for inpatient hospital care.  
 
Records show that you were in the hospital for three days. You have been asked to pay a $285 copayment per 
day for this inpatient hospital care. 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 hospital 
care you received from September 3, 2020, to September 7, 2020.  
 
Please note that if you have questions regarding your Plan's Medical Financial Assistance Program, you will 
need to contact your Plan directly. Maximus does not have jurisdiction to review any issues or questions related 
to this program.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility admission.

You asked the Plan to pre-approve a skilled nursing facility (SNF) admission. You say that you have not gotten enough therapy at the hospital to safely discharge home. The Plan denied your request. The Plan says you are receiving adequate and necessary intensive rehab in the inpatient rehabilitation facility.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pre-approve a skilled nursing facility (SNF) admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient has no complex wound care or other skilled nursing need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a skilled nursing facility 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 a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization inpatient care.

You asked the Plan to pay for the post-stabilization inpatient care. You say that the services were medically
necessary. The Plan denied your request. The Plan says the enrollee was stable for transfer to a plan-contracted
facility after initial stabilization.

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 inpatient care. Our
reviewer says that the post-stabilization inpatient care was 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 patient
was not stable for transfer to a plan facility 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 inpatient care have not been met. Therefore, we decided
that the Plan does not have to pay for post-stabilization inpatient care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis
code.

We looked at the file and Medicare rules. The file shows that the claim was not billed with a proper diagnosis
code. Based on this information, we decided that Medicare rules for coverage of these services have not been
met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interspinous process decompression device surgery.

You asked the Plan to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction
device, without open decompression or fusion, including image guidance when performed, lumbar; single level
(22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open
decompression or fusion, including image guidance when performed, lumbar; second level (22870). You say
that this is the best treatment for you as physical therapy and pain medications are not helping ease the pain.
The Plan denied your request. The Plan says there are not enough studies to show the interspinous process
decompression device is safe and effective.

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 Insertion of interlaminar/interspinous
process stabilization/distraction device, without open decompression or fusion, including image guidance when
performed, lumbar; single level (22869) and Insertion of interlaminar/interspinous process
stabilization/distraction device, without open decompression or fusion, including image guidance when
performed, lumbar; second level 22870). Our reviewer says that the requested items/services are not considered
medically reasonable and necessary in this case. Our physician reviewer found the interspinous spacer device
remains experimental. High failure rates have been reported. 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 Insertion of interlaminar/interspinous process stabilization/distraction device,
without open decompression or fusion, including image guidance when performed, lumbar; single level
(22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open
decompression or fusion, including image guidance when performed, lumbar; second level (22870) have not
been met. Therefore, we decided that the Plan does not have to pre-approve interspinous process
decompression device surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia for the enrollee.

You asked the Plan to pre-approve Orencia. You say that the enrollee is stable on this medication. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Orencia for the enrollee.

Please note, the case file indicates the Plan has approved Orencia under the enrollee's Medicare Part D benefit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care that you provided on 
September 24, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 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 subsequent nursing facility care that you provided on September 
24, 2020.
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 needs IRF care. The Plan denied your
request. The Plan says IRF services are not medically necessary, care can be provided at a lower level of 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 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 patient 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 this patient 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Arthrocentesis.

You asked the Plan to waive the copayment for Arthrocentesis (20604). You say that no one advised you that
you could have this procedure done at a place with a lower cost option. The Plan denied your request. The Plan
says you were charged this copayment 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 $350
copayment for Outpatient Surgery in an outpatient hospital facility.

You have been asked to pay a $266.04 copayment for Arthrocentesis. Arthrocentesis falls within the Outpatient
Surgery benefit category. The allowed amount for the procedure was less than your required copayment. 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 Arthrocentesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve teeth extractions (D7210), bone graft implants (D6010, D6104) and imaging 
(D0220, D03330). You say that because of a medical condition the enrollee needs these dental services. The 
Plan denied your request. The Plan says this procedure is not for reduction of a fracture of the jaw or facial 
bone. 
 
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 pre-approve 
dental services.