Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a behavioral health inpatient admission provided from May 
12, 2020, through 
May 22, 2020. 
 
You asked the Plan to pay for the behavioral health inpatient admission. The Plan denied your request. The 
Plan says prior authorization was not obtained by the provider or the facility. 
 
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 
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 a behavioral health inpatient admission provided from May 12, 
2020, through May 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six home health skilled nursing visits. 
 
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 three visits are approved and six further are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the home health note dated October 2, 
2020, states that the enrollee needs assistance for transfers and uses a wheelchair. There are no skin issues or 
wounds. She is able to repeat prior colostomy care education. She is independent with taking medications and 
for functional mobility and transfers. The enrollee does not have documented skilled needs. Continued home 
health services beyond the three approved visits are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six home health skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE) (93306). 
 
You asked the Plan to pre-approve a transthoracic echocardiography. You say that this is an appeal to the 
denial for coverage on his echocardiogram. Please see attached documentation including his symptoms and 
treatment plan. The Plan denied your request. The Plan says this enrollee does not meet the medically 
necessary criteria for the transthoracic echocardiography. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a transthoracic echocardiography. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this circumstance the symptoms and physical exam described do not 
support the medical necessity for a repeat echocardiogram about 1 year from the prior exam. There is no 
documentation of jugular venous pulse elevation to support the mild edema may be on a cardiac basis and no 
prior significant valve disease or left ventricle dysfunction to support the medical necessity for a repeat 
echocardiogram at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a transthoracic echocardiography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a transthoracic echocardiography (TTE) (93306).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) and 
comprehensive oral evaluation (D0150) provided on July 1, 2020. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test and comprehensive oral evaluation. You say 
that you contacted the Plan, were given a list of in-network providers, and the provider you saw was on that 
list. You also say that you were not aware of the Plan limitations. The Plan denied your request. The Plan says 
adjunctive pre-diagnostic test is not a covered benefit. The Plan also says that the comprehensive oral 
evaluation exceeds the frequency limitation in your benefit plan. 
 
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, adjunctive pre-diagnostic test (D0431) 
is not among those covered under this benefit. The contract also says that comprehensive oral evaluations 
(D0150) are limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on April 19, 2019, and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-
diagnostic test (D0431) and comprehensive oral evaluation (D0150) provided on July 1, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on June 2, 2020. 
 
You asked the Plan to pay for the psychotherapy services. 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 psychotherapy services provided on June 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone. 
 
You asked the Plan to pre-approve the Testosterone. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says Testosterone topical gel is denied as a benefit 
exclusion. 
 
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 Testosterone.  
 
Benefits for the Testosterone 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
April 8, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is no itemized billing/shipping invoice to verify the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a proof of delivery to support medical necessity for the supplies provided in this 
case. There is no itemized billing/shipping invoice to verify the services billed. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on April 8, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient admission requested on October 14, 2020. You asked the Plan to pre-approve the inpatient admission. You say that the enrollee requires an inpatient level of care for her condition. The Plan denied your request. The Plan says that the enrollee's care could have been provided as outpatient observation. 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 the inpatient admission. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department reporting shortness of breath and weakness. Emergency care included laboratory studies, radiologic imaging, and telemetry. The enrollee was noted to have an elevated blood pressure, a right sided pleural effusion and noted to have ongoing chronic anemia. It was determined ongoing hospital care was required. The enrollee was placed in the medical intensive care unit for monitor and treatment of her blood pressure as well as planned thoracentesis.The medical records provided indicate that the admitting physician expected the enrollee's admission to span two 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 the inpatient admission have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient admission requested 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on May 6, 2020. 
 
You asked the Plan to pay for the drug test. 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 and the referring provider are not network providers with the Plan. The Plan 
did not pre-approve the drug test. 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 a drug test provided on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA). 
 
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 the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. 
She had prior RFA of the lateral sacral branches with excellent results. The requested repeat RFA of the lateral 
sacral branches is considered experimental/investigational in nature due to the wide variation in efficacy 
reported in peer-reviewed literature. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat radiofrequency ablation (RFA).  
 
Local Coverage Determination (LCD) L33622 referenced by the Plan is not binding for the state of Michigan 
and was not used in the MAXIMUS determination.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental for use in cases of spinal fusion surgery. 
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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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 rules for IRF are have 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 that 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's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires an 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapeutic phlebotomy provided by an 
outpatient hospital on May 21, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital service. You say that you do not believe that 
you owe this amount. The Plan denied your request. The Plan says the copayment amount you are being 
charged is correct. 
 
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 $250 
copayment for outpatient hospital services.  
 
You have been asked to pay the allowed amount of $110.73, which is less than the $250 copayment for 
outpatient hospital service. Outpatient hospital service falls within the Outpatient Hospital Services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for therapeutic phlebotomy provided by an 
outpatient hospital on May 21, 2020.
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 enrollee needs close monitoring and attention 
from medical professionals. The Plan denied your request. The Plan says it is not reasonable to expect the 
enrollee will be able to take part in 3 hours of therapy a day. 
 
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 physician reviewer found 
that the enrollee is at a minimal assist level for bathing and dressing, a supervision level for grooming toileting, 
and bed mobility. The complexity of the enrollees nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Her medical status does 
not currently require intensive physician and nursing oversight only in an IRF. She may benefit from physical 
and occupational therapy, but the documentation does not support that the enrollees functional status requires 
an 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: 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 is unable to walk unassisted due to 
weakness from being on a ventilator. You say that physical therapy and occupational therapy services are 
needed. You say that the medical records provided support the need for IRF care. The Plan denied your request. 
The Plan says the guidelines for coverage of IRF care have 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 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's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires or can tolerate an 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: 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 you cannot go home and need additional assistance. 
The Plan denied your request. The Plan says that you do not have complex nursing or medical needs requiring 
a resource intensive inpatient hospital setting. 
 
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. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be 
able to perform, fifteen hours per week of rehabilitative services and regular physician evaluation. Your care 
needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet 
Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.