Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided from 
November 24, 2020, to December 13, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you believe these services 
should be covered. The Plan denied your request. The Plan says the enrollee did not meet criteria for continued 
sub-acute level of care in the skilled nursing 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 pay for the subsequent nursing facility care. Our 
reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found 
the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the subsequent nursing facility care have not been met. Therefore, we decided 
that the Plan does not have to pay for the subsequent nursing facility care provided from November 24, 2020, 
to December 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hand x-ray (73130) provided on October 12, 2020. 
 
You asked the Plan to pay for the hand x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the diagnosis codes associated to this claim are 
mismatched with the services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 73130 is not supported in the record. Specifically, this claim was billed with a diagnosis 
code indicating the right side but this code was billed with a modifier indicating the left side. There is a more 
appropriate diagnosis code for the service billed. Based on this information, we decided that Medicare rules for 
coverage of the hand x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the 
hand x-ray (73130) provided on October 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grab bar. 
 
You asked the Plan to pre-approve a grab bar. You say that you need this for your bathtub. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with an Endodontist. 
 
You asked the Plan to pre-approve the consultation with an Endodontist. You say that you would like this 
service to be covered with a specialist in order to find the cause, and possibly receive treatment to alleviate 
your pain. The Plan denied your request. The Plan says your contract only provides coverage for dental 
services when they are performed by a participating general dentist. The Plan also says that dental services 
performed by an Endodontist are not covered. 
 
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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a consultation with an Endodontist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0800). 
 
You asked the Plan to pre-approve power wheelchair. You say that the power wheelchair is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not show that you have a mobility deficit that impairs your participation in MRADLs. The record 
shows that the ankle pain is sporadic and there is no documentation to show that your condition cannot be 
improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis (L1971 and A9900) provided on 
September 19, 2020. 
 
You asked the Plan to pay for the ankle foot orthosis. You say that you would like reconsideration because this 
equipment is medically necessary. The Plan denied your request. The Plan says Medicare beneficiaries are 
eligible for telehealth services only if they are presented from an originating site. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ankle foot orthosis have not been met. Specifically, the documentation submitted does not 
include any clinical information to determine if Medicare coverage criteria have been met. There is no 
indication that the member requires stabilization or has the potential to benefit functionally. Therefore, we 
decided that the Plan does not have to pay for the ankle foot orthosis (L1971 and A9900) provided on 
September 19, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Orthovisc. 
 
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 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has pain related to right 
shoulder osteoarthritis, confirmed on imaging studies. She has failed conservative treatment. The records and 
Medicare-approved major drug compendia support the use of Orthovisc for the enrollee's condition. Orthovisc 
is safe and effective and reasonable and medically necessary as an off-label use for the enrollee 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve Orthovisc.  
 
Local Coverage Article (LCA) A56157 referenced by the Plan is not binding and was not used in the MAXIMUS determination. 
 
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: Favorable

 
We decided that the Plan has to pre-approve a segmental pneumatic appliance for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no four-week trial of a basic device. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found in this case, the enrollee has upper extremity edema that extends to the chest wall. The notes indicate that 
the enrollee began using a basic pump in November 2020 and continued through January 2021 with a failure to 
improve. The requested service is recommended. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a segmental pneumatic appliance for the enrollee.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Liquid CDx testing provided on October 7, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the Liquid CDx panel. You say that you would like reconsideration because the 
test results were needed to help determine the course of treatment for this member. The Plan denied your 
request. The Plan says utilization of network providers is required when possible and available. 
 
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 the Liquid CDx testing provided on October 7, 
2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for nursing facility care (99309) and debridement (11042 and 11043) 
provided on October 14, 2020. 
 
You asked the Plan to pay for the nursing facility care and debridement. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that this claim 
was not submitted with a valid provider type. 
 
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. Specifically, the Plan has failed to forward sufficient evidence as to why the 
provider type is invalid. It is the burden of the Health Plan to substantiate their decision with evidence. This 
denial is not substantiated; therefore, we must find in your favor Therefore, we decided that the Plan has to pay 
for nursing facility care (99309) and debridement (11042 and 11043) provided on October 14, 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 pre-approve the insertion of a Coflex device (22867). 
 
You asked the Plan to pre-approve the insertion of a Coflex device. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is experimental. 
 
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 insertion of a Coflex device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Coflex device remains experimental in cases of spinal fusion surgery. There 
is also no documented spinal instability on flexion and extension x-rays, meaning hardware is not indicated 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 insertion of a Coflex device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the insertion of a Coflex device (22867).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal maintenance and four periodontal scalings 
and root planings to be provided by you, an OON provider. 
 
You asked the Plan to pre-approve the periodontal maintenance and periodontal scalings and root planings. The 
Plan denied your request. The Plan says you are an OON provider. The Plan also says that services are only 
covered by the enrollee's Health Plan when they are rendered by in-network dentists. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve 
periodontal maintenance and four periodontal scalings and root planings to be provided by you, an OON 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sure 140MG/ML Injection, for the enrollee. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has severe coronary disease and 
cholesterol is not optimally controlled on maximally tolerated statin, and fish oils. The Plan denied your 
request. The Plan says the enrollee's Plan does not cover outpatient prescription drugs. 
 
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 Repatha Sure 140MG/ML 
Injection, for the enrollee.  
 
Benefits for the medication 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: 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 in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for acute kidney failure and a urinary tract infection. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and 
Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not 
been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 
10, 2020 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee has no choice in 
the medical professional they are seen by while in the facility. You also say that you rely on the facility to 
obtain any necessary authorization. The Plan denied your request. The Plan says the treating provider is not in-
network, and there is no authorization on file. 
 
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 
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 subsequent nursing facility care provided on 
September 10, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a motorized wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says you can self-propel with a manual wheelchair in the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found a motorized 
wheelchair that has a seat lift is not medically necessary. You are currently able to participate in MRADLs in 
the home with his scooter and with a manual wheelchair. You do not require the requested wheelchair as he can 
use your current scooter and a manual wheelchair. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a motorized wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission for a knee arthroplasty (27447). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee can be treated as an outpatient. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the submitted documentation does not indicate a sufficient medical 
rationale of why an inpatient stay of two midnights is prospectively anticipated. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient admission for a knee arthroplasty (27447).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography (93313) provided on July 7, 2020. 
 
You asked the Plan to pay for the echocardiography. You say that you would like reconsideration because this 
service was billed correctly. The Plan denied your request. The Plan says modifier QZ as an inappropriate 
modifier for the CPT code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 93313 is not supported in the record. Specifically, this claim was submitted with an 
inappropriate modifier. QZ is a modifier for anesthesia fee schedule codes and 93313 is not payable on the 
anesthesia fee schedule. Based on this information, we decided that Medicare rules for coverage of the 
echocardiography have not been met. Therefore, we decided that the Plan does not have to pay for 
echocardiography (93313) provided on July 7, 2020.