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

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the requested IRF admission 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 that 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 may have 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 IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing identified with codes 96133 
(four units) and 96139 (nine units). 
 
You asked the Plan to pre-approve neuropsychological testing identified with codes 96133 (four units) and 
96139 (nine units). You say that you disagree with the Plan's denial. The Plan denied your request. The Plan 
says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is only covered for certain 
indications. 
 
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 neuropsychological testing identified 
with codes 96133 (four units) and 96139 (nine units). Our reviewer says that the documentation does not 
support that the requested services are medically reasonable or necessary. Our physician reviewer found the 
requested  testing is intended to diagnose and characterize the neurocognitive effects of medical disorders that 
impinge directly on or indirectly on the brain including detection of neurologic disease based on quantitative 
assessment of neurocognitive abilities, differential diagnosis between psychogenic and neurogenic syndromes, 
delineation of neurocognitive effects of central nervous system disorders, neurocognitive monitoring of 
recovery or progression of central nervous system disorders or assessment of neurocognitive function for the 
formulation of rehabilitation and/or management strategies among individuals with neuropsychiatric disorders. 
The request for neuropsychological testing is for what appears to be diagnostic clarification of memory loss 
along with treatment planning. The enrollee's needs can be sufficiently met with the approved testing. 
Therefore, the enrollee does not meet criteria for additional testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing identified with codes 96133 (four units) and 96139 
(nine units) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
neuropsychological testing identified with codes 96133 (four units) and 96139 (nine units).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes U0003 and U0005 
for September 2, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that infectious disease pathogen testing is covered 
when specific criteria are met. 
 
We looked at the file and Medicare rules. There is no documentation of laboratory results to support that the 
criteria for coverage are met. 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 laboratory services 
billed with codes U0003 and U0005 for September 2, 2022.
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 you are requesting reconsideration for the denial of 
admission to an IRF. The Plan denied your request. The Plan says criteria for admission to the IRF setting 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a third level facet joint injection provided on  
September 13, 2022. 
 
You asked the Plan to pay for the third level facet joint injection. You say that a third level facet joint injection 
was medically necessary. The Plan denied your request. The Plan says a third level facet joint injection does 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 third level facet joint injection. Our 
reviewer says that a third level facet joint injection was not medically necessary in this case. Our physician 
reviewer found that according to the Medicare coverage criteria: One to two levels, either unilateral or bilateral, 
are allowed per session per spine region. The need for a three or four-level procedure bilaterally may be 
considered under unique circumstances and with sufficient documentation of medical necessity on appeal. A 
session is a time period, which includes all procedures (i.e., medial branch block (MBB), intraarticular 
injections (IA), facet cyst ruptures, and RFA ablations that are performed during the same day. The review has 
determined that the requested third level fact joint injection does not meet the Medicare LCD coverage criteria. 
 
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 third level facet joint injection have not been met. Therefore, we decided 
that the Plan does not have to pay for a third level facet joint injection provided on September 13, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the sinuses. 
 
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. Medicare rules say that CT 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has a history of bloody 
rhinorrhea after a dental extraction. A nasal endoscopy was suspicious for sinusitis. The bloody nature of the 
rhinorrhea needs to be investigated and the best way after the nasal endoscopy would be the requested CT of 
the sinuses. The services are 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the sinuses.  
 
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 lab services provided to the enrollee on April 22, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that while they agree an exception to the date of service rule likely applies in this case, this is an administrative determination for billing and is not based on clinical criteria for medical necessity. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service. However, the specimen was collected during an outpatient encounter. Therefore, POS code 81 would not apply.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim cannot be paid due to an error with the POS code submitted on the claim. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on April 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), the electrical 
connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) 
and harness (E2313). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial. The Plan 
denied your request. The Plan says although there are two approved power options on this wheelchair, there is 
not a medical need to control these power options through the joystick. Notes state that member is independent 
with light housework and bladder management with urinal or self-catheterization. Member's upper limb 
strength and function are adequate for the member to be able to control the power options using their own 
switches which are included in the allowance of these power options. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided records document that the enrollee has adequate upper extremity strength 
and function to independently use a urinal bottle and to perform self-catherization and to perform light 
housework, thus indicating she has adequate upper extremity strength and function to operate the wheelchair's 
power options with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power seat elevation system (E2300), the electrical connection between the 
wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D4921 and D4381) on September 8, 
2022. 
 
You asked the Plan to pay for the dental services (D4921 and D4381). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pay for the dental 
services (D4921 and D4381) on September 8, 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 you need to go to a skilled nursing facility (SNF). The Plan denied your request. The Plan says that the IRF care is not medically necessary, and that your needs can be met at a lower level of care such as at home with supervision and home health services.
Our Medical director looked at the case file and the reopen request. At issues is coverage for IRF care. Our Medical Director states that the documentation does not support that you needed the specialized training, staff, or equipment available only in an IRF. The documentation does not support that you needed to be assessed medically and functionally face-to-face by a rehab doctor, at least three days per week. Services could have been provided in other settings. Our Medical Director found that your condition did 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.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the Transcranial Magnetic Stimulation (TMS) treatments provided from August 17, 2021, to October 20, 2021.
You asked the Plan to waive the copays for the TMS treatments. You say that you were told these treatments would be fully covered by the plan prior to committing to them. The Plan denied your request. The Plan says this cost sharing was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copay per individual or group therapy visit for outpatient mental health care. You have been asked to pay a $40 copay for each of the TMS treatments. This item/service falls within the individual or group therapy visit for outpatient mental health 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 copays for the Transcranial Magnetic Stimulation (TMS) treatments provided from August 17, 2021, to October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that supporting documents were provided. The Plan 
denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. 
 
We find that code 87150 is a column II code to column I code 87500. The records do not show that CPT code 
87150, billed with an XU modifier, was an unusual, non-overlapping service. Based on this information, we 
decided that Medicare rules for coverage have not been met. 
 
We find that the MUE for CPT code 87500 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. The documentation does not show that the excess units were actually provided, were 
correctly coded, and were medically necessary. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on August 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thyroid stimulating hormone (TSH) (84436), and thyroxine, 
total (84443) testing provided on August 3, 2022. 
 
You asked the Plan to pay for TSH and thyroxine testing. You say that these services were medically 
necessary. The Plan denied your request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, TSH and thyroxine testing, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for thyroid stimulating hormone (TSH) (84436), and thyroxine, total (84443) testing provided on 
August 3, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing services provided on April 11, 2022.
You asked the Plan to pay for the testing. You say that these services were medically necessary. The Plan denied your request. The Plan says the specimen was collected in a hospital.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing services provided on April 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee continues to report suicidal 
ideation. The Plan denied your request. The Plan says the enrollee's care could be safely provided in a different 
setting. 
 
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 the requested services. Our physician 
reviewer found that the enrollee presented to the acute inpatient psychiatric hospitalization on February 13, 
2023, with bipolar disorder, most recent episode depressed.  This enrollee presented with racing thoughts, anxiety and depression. This enrollee had suicidal thoughts with 
no plan. This enrollee has been paranoid about the people in the personal care at the facility she is at. Based 
upon review the records provided it is not expected this enrollee would improve in a reasonable period of time 
as she does not have dangerousness to self or others and is not showing any auditory/visual hallucinations or 
any aggressive behaviors. It does not appear that the services are reasonably expected to improve the enrollees 
condition or for the purpose of diagnosis. Therefore, the request is not 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient psychiatric services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation for knee surgery. 
 
You asked the Plan to pre-approve computer-assisted surgical navigation. You say that this procedure was 
approved in the past. The Plan denied your request. The Plan says studies have not proven that this is helpful 
with the requested surgery. 
 
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 computer-assisted surgical navigation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no large volume, long-term/high-quality clinical study that 
confirms clinical benefits of computer-assisted surgery over standard surgical approaches in total knee 
arthroplasty.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted surgical navigation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve computer-assisted surgical navigation for knee surgery.