Persius/hicric huggingface dataset:
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 currently hospitalized and needs 
inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee does not meet all of the 
required Medicare criteria for admission to an IRF. The Plan says that the enrollee is close to his baseline 
function and does not have any medical conditions that require regular nursing and physician oversight. 
 
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 surgical repair of a femur fracture after a fall. The enrollee's 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 enrollee has a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stab phlebectomy with ligation and stripping. 
 
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 for treatment of the greater saphenous 
vein to be covered, there needs to be a demonstration of reflux in the respective vein. In this case, there is 
documentation that the vein is thrombosed throughout the thigh and calf (no reflux). Additionally, there is no 
mention in the provider assessment that there is any plan to perform stripping of the greater saphenous vein and 
therefore this cannot be approved. With respect to stab phlebectomy, there is inadequate description of current 
symptoms. The information regarding symptoms was admitted as an addendum. However, the conditions that 
existed when the symptoms were described no longer exist. The veins in question have all thrombosed. There 
has not been sufficient time to reevaluate the enrollees symptoms in the absence of reflux. Evaluation of 
symptoms will not be accurate until several months have passed giving time for the inflammation of the 
phlebitis to resolve. 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 stab phlebectomy with ligation and stripping.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long-term custodial care provided from December 1, 2017, to 
February 1, 2022. 
 
You asked the Plan to pay for long-term custodial care. You say that your share of costs for this should be $0. 
The Plan denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of long-term custodial care have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for long-term 
custodial care provided from December 1, 2017, to February 1, 2022.
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 requested IRF care is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical necessity rules for 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 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 that 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. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that the 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services received on November 7, 2021. 
 
You asked the Plan to pay for the services. You say that it would have cost more money to go to the hospital. 
The Plan denied your request. The Plan says no payment can be made. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 7, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services received on November 7, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. At this time, more research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Genvisc (J7320). 
 
You asked the Plan to pre-approve Genvisc. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Genvisc. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Orthovisc, Synvisc, or Synvisc-One before they will approve the requested drug. 
The enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the 
Plans required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Genvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Genvisc (J7320).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional routine transportation trips. 
 
You asked the Plan to pre-approve 12 additional routine transportation trips. You say that it is necessary for 
you to continue receiving transportation to the doctor. The Plan denied your request. The Plan says although 
this a covered benefit under the Plan, the benefit has been exhausted at this time. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 12 additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from August 25, 2021, to September 16, 2021. 
 
You asked the Plan to waive the copayment for the SNF care. You say that the stay should be fully covered 
with no additional cost to you. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $0 per 
day for days 1-20 and $178 per day for days 21-100 for each benefit period.  
 
 The file shows that you were in the skilled nursing facility from August 25, 2021, to September 16, 2021. You 
were not charged for the first 20 days from August 25, 2021, to September 13, 2021. Therefore, you have been 
asked to pay $178 per day for days 21-22 of SNF care from September 14, 2021, to September 15, 2021 (there 
is no copayment on the discharge date). The total for your stay is $356 ($178 copayment x 2 days = $356). The 
SNF care falls within the Skilled Nursing Facility (SNF) Care 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 skilled nursing facility (SNF) care provided from August 25, 2021, to September 
16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on January 21, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that authorization was not obtained 
prior to seeing this patient since it is the nursing facility's responsibility to get authorizations for their patients. 
The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and they 
have also determined that these services were 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 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 a domiciliary or rest home visit provided on 
January 21, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic mammography (77066) and a digital breast 
tomosynthesis (G0279) provided on December 3, 2021. 
 
You asked the Plan to pay for a diagnostic mammography and a digital breast tomosynthesis. You say that you 
have provided records to support the services billed. The Plan denied your request. The Plan says rules for 
payment have not been met because the claim at issue is a duplicate claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a diagnostic mammography and a digital breast tomosynthesis have not been met. Specifically, the 
Plan has documented that the claim at issue is a duplicate of a prior claim that has been processed and paid. 
Therefore, we decided that the Plan does not have to pay for a diagnostic mammography (77066) and a digital 
breast tomosynthesis (G0279) provided on December 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient services provided on October 
8, 2021, November 19, 2021, and December 3, 2021. 
 
You asked the Plan to waive the copayment for outpatient services. You say that you were not told you had a 
copayment, and you cannot afford to pay the bills. The Plan denied your request. The Plan says the copayment 
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 $295 
copayment for in-network, outpatient hospital surgery and $20 copayment for outpatient hospital services 
rendered by an in-network physician specialist.  
  You have been asked to pay a total of $610 for the outpatient services.  
 
Date of Service Service Allowed Amount Standard Copayment Member Liability 
October 8, 2021 Debridement $417.80 $295 $295 
November 19, 2021 Application of 
Paste Boot 
$170.56 $20 $20 
December 3, 2021 Debridement $417.80 $295 $295 
TOTAL:    $610 
 
The debridement and application of paste boot fall 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 the outpatient services provided on October 8, 2021, 
November 19, 2021, and December 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluorodeoxyglucose (FDG)-positron emission 
tomography (PET) scan of the brain for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 scan. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the provider's notes 
only suggested a difference between Alzheimer's disease (AD) and vascular dementia. There was no indication 
that fronto-temporal dementia (FTD) was suspected - and as such the enrollee would not meet diagnostic 
criteria for this disorder). 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan of the brain for the 
enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the laboratory services and the pathology 
services provided on November 22, 2021, and November 24, 2021. 
 
You asked the Plan to waive the copayments for the laboratory services and the pathology services. You say 
that you were scheduled for your annual physical and you received a bill with the copayments on it. The Plan 
denied your request. The Plan says the annual wellness visit does not include lab test and the proper 
copayments were applied. 
 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 $10 
copayment per day, per provider, for Medicare-covered lab services and $10 per day, per provider, for 
Medicare-covered pathology services. On November 22, 2021, and November 24, 2021, there was a copayment 
amount of $10 for each date of service. The total copayment amount for both dates of service was $20 ($10 
copayment + $10 copayment). 
 
You have been asked to pay a $20 copayment for the laboratory services and the pathology services. The 
laboratory services and the pathology services falls within the Outpatient diagnostic tests and therapeutic 
services and supplies 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 copayments for the 
laboratory services and the pathology services provided on November 22, 2021, and November 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from June 26, 2021, to
June 30, 2021.
You asked the Plan to pay for this claim as billed. You say that this claim should be paid as billed. The Plan
denied your request. The Plan says the records provided do not support the diagnosis billed.
Maximus overturned the Plans denial for insufficient records. The Plan requested a reopen and provided
additional information.
Our Medical Director looked at the case file and the reopen request. At issue is the downgrade of DRG for the
principal diagnosis and secondary diagnosis. The medical records show the enrollee was a 76-year-old man
with a history of COPD, diabetes, and cholelithiasis, who underwent an elective laparoscopic cholecystectomy
on June 25, 2021. The enrollee presented to the emergency department on June 26, 2021, with abdominal pain
and distention, with vomiting. Generalized abdominal tenderness; no guarding or rebound. WBC elevated
(16.3), lactic acid elevated (2.8). IV antibiotics started. Small bowel gas pattern was non-specific. On June 27,
2021, the notes stated diagnoses of sepsis, pneumonia vs atelectasis and ordered a septic work up. On June 28,
2021, the progress notes state no growth on blood cultures. Specifically, "No signs of sepsis or obvious
infection. Possible post-op ileus? Seems to have resolved". On June 30, 2021, the enrollee was cleared to go
home. While postoperative ileus may be appropriate sepsis would not be supported as a secondary diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient care provided to the enrollee from June 26, 2021, to June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided to the enrollee from May 10, 
2021, to May 20, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says no payment is allowed for add-on codes. 
 
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, we have confirmed that code 99292 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for hospital services provided to the enrollee from May 10, 2021, to May 20, 2021.