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

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says care in a SNF must meet certain care points. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you have stabilized medically, without 
any acute exacerbations of chronic medical problems, and you are ready for discharge from the hospital. You 
do not require skilled nursing and/or skilled therapy services on a daily basis. As you are stable, you can 
receive further rehab services at a lower level of care. Although further rehab services would be appropriate to 
improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care 
than a skilled nursing facility. You do not have any parental medication; complex wound care or nutrition 
given via a feeding tube. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provider on October 5, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they 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 did not pre-approve the 
physician's services. 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 physician's services provider on October 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve clinical crown lengthening (D4249) for tooth #31. 
 
You asked the Plan to pre-approve the clinical crown lengthening. You say that your dentist advised you that 
gum work could be causing these problems and should be addressed. You say that you have severe pain from 
this. You also say you think outside air could be hitting your nerve. The Plan denied your request. The Plan 
says clinical crown lengthening is not listed as a covered service. 
 
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 
clinical crown lengthening (D4249) for tooth #31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve excision of hyperplastic tissue-per arch (D7970). 
 
You asked the Plan to pre-approve the dental services. You say that please reconsider the denial and approve 
the procedure so you can have the surgery as soon as possible. You cannot eat very well and al lot of things you 
cannot eat at all. The Plan denied your request. The Plan says this service is not covered under the plan 
benefits. 
 
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. The health plan contract on 
page 4-89 specifically says that any service not listed are not covered. 
 
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 
excision of hyperplastic tissue-per arch (D7970).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy and biopsy (45380) 
performed August 6, 2020. 
 
You asked the Plan to waive the copayment for the colonoscopy and biopsy. You say that the service should be 
billed as preventive instead of diagnostic. The Plan denied your request. The Plan says since a biopsy was 
taken during the procedure the claim was correctly processed as a diagnostic colonoscopy, and therefore is not 
considered preventive. 
 
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 hospital services.  
 
You have been asked to pay a $350 copayment for the colonoscopy and biopsy. A colonoscopy and biopsy falls 
within the outpatient hospital services benefit category. The record shows that a biopsy was performed during 
this procedure. This means that the service at issue is considered diagnostic, and not preventive. 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 colonoscopy and biopsy (45380) performed August 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee could be treated at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found it is not medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care 
as the enrollee was not a danger to himself or others and was cooperative and compliant. It did not appear that 
active treatment was taking place or that the services were reasonably expected to improve the patient's 
condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Specifically, care could have been 
provided at a lower level of care. Therefore, we decided that the Plan does not have to pre-approve inpatient 
psychiatric care.
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. The Plan denied your request. The Plan says you do not need 
three hours a day of therapy, and her medical illnesses are stable. 
 
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 you were admitted to the acute hospital for an iliocolectomy. There is ongoing weakness, but your medical 
conditions are stable. You do not require treatment by multiple therapies, or an intensive rehabilitation therapy 
program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. 
 
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: Imaging
Decision: Favorable

We decided that the Plan does not have to pay for physician services billed for code 71045 on April 20, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were met. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information. The Plan says that it has been determined that this
claim denied because the provider billed with an inappropriate modifier. The claim shows code 71045 was
billed with modifier 26, but this was incorrect. The Plan says the provider needed to bill with modifier 59 to
show as a separate encounter in order for payment to be processed. The Plan also states that this service was
previously paid to another provider in the same specialty group. The Plan states the NPI website shows that
both providers practice Radiology and belong to the same practice group. The Plan says that for payment
consideration, the correct billing of this service needed to include modifier 59 to distinguish a separate and
distinct service.
The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same
day to the same patient by the same physician or more than one physician in the same specialty in the same
group, only one service may be reported unless the services are for unrelated problems. Based on the
documentation provided, this claim cannot be paid as billed due to the physician group relationship between the
two providers and the omission of the modifier required to identify this as a separate and distinct service.
Medicare billing criteria were not met.
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on
April 20, 2020 and billed under the above identified claim.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is currently no clinical indication for this technology. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a request for platelet-rich plasma injection was made. Knee pain is not an indication for platelet-rich 
plasma injections which is also an investigational treatment still due to lack of high quality data to support it's 
general use. Therefore, this request for such will be considered not medically necessary 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve platelet rich plasma injection for the enrollee.
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 you would like reconsideration because 
the member meets criteria and LTACH admission will sustain a safe discharge. The Plan denied your request. 
The Plan says these services can be safely provided in a lower 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician office visit services provided on July 31, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for physician office visit services. You say that you were trying to start the process 
to become an HMO member. The Plan denied your request. The Plan says prior authorization was not obtained. 
The Plan says that these services were provided in an out-of-network 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 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 physician office visit services provided on July 31, 
2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
September 16, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received a diagnostic colonoscopy on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $300 
copayment for a Diagnostic Colonoscopy.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a diagnostic 
colonoscopy on September 16, 2020. You have been asked to pay a $300 copayment for the diagnostic 
colonoscopy. The diagnostic colonoscopy falls within the Diagnostic Colonoscopy 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 the diagnostic colonoscopy provided on September 16, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical 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 procedure code 26440 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 26440 is tenolysis, flexor tendon; palm OR finger, each 
tendon. 
 
We find that CPT code 26440 is not supported in the medical record. Specifically, the operative report does not 
contain documentation of tenolysis of a flexor tendon. 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 surgical services rendered.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is considered a convenience item. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 shower chair.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance services and the emergency 
room services provided on July 21, 2020. 
 
You asked the Plan to waive the copayments for the ambulance services and the emergency room services. You 
say that you feel you should not be responsible for this cost share amount and you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says you received ambulance services and 
emergency room services on the date of service at issue in this appeal. The Plan says that the correct 
copayments have applied per your contract with the Plan. 
 
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 $310 
copayment for Ambulance services and a $90 copayment for Emergency care. 
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received ambulance 
services and emergency room services on July 21, 2020. You have been asked to pay a $310 copayment for the 
ambulance services. The ambulance services fall within the Ambulance services benefit category. You have 
been asked to pay a $90 copayment for the emergency room services. The emergency room services fall within 
the Emergency care benefit category. This means that you have been asked to pay the correct amounts 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 copayments for the ambulance 
services and the emergency room services provided on July 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for train of four testing provided on February 25, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the cost is 
included in the cost of the primary procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. All services integral to accomplishing a procedure are considered bundled 
into that procedure Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for train of four testing provided on February 25, 
2020.