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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs are custodial and, as a 
practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Therefore, LTACH services will be considered not medically 
necessary as transfer would not be clinically advantageous. 
 
 
 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that your previous ablations have kept you 
from taking opioids or drinking alcohol. The Plan denied your request. The Plan says the requested services are 
not medically necessary. The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation 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 radiofrequency ablation. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found you have chronic low back pain. You are status post lumbar fusion with 
continuing back pain. You are taking Baclofen and Gabapentin for pain. You previously had radiofrequency 
ablation of the sacroiliac joints and had three years of relief. The request is considered experimental because of 
the wide variation in efficacy reported in the literature. Therefore, you do not meet criteria for the requested 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on December 22, 2020 
and billed under code G0480. 

You asked the Plan to pay for this claim. You say that this testing should be covered by the Plan. The Plan 
denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans 
denial. The Plan requested a reopen and provided additional information. The Plan says that that this claim   
denied because the provider billed this service inappropriately. The Plan states this service had been paid under 
a previously submitted claim with a primary code of G0483. The medical records do not support why this 
procedure had been rendered twice on the same day.  
 
There are no modifiers associated with NCCI that can be used with this PTP code pair; there are no 
circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the 
same day by the same provider. As both providers are with the same group, the claims must be billed correctly 
if they are a separate and distinct service. 
 
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 codes. In this case, the claim in 
question was billed inappropriately. This service was billed by another provider in the same group on a 
previous claim. This claim has not been billed with an appropriate modifier to bypass the edit from the previous 
claim. Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
drug testing provided to the enrollee on December 22, 2020 and billed under code G0480.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper and lower denture (D5110 and 
D5120). 
 
You asked the Plan to pre-approve the complete upper and lower denture (D5110 and D5120). You say that 
your old dentures were big and caused mouth sores, so you have to get new dentures that fit. You say that you 
are on a fixed income and you should not have paid out of pocket. The Plan denied your request. The Plan says 
a complete upper and lower denture are only covered once every five plan years. 
 
 
 
 
 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, you also have a maximum benefit of 
one complete upper and lower denture every five plan years. The Plan paid for the complete upper and lower 
denture provided on September 6, 2019, which exhausted your benefit. Therefore, we decided that the Plan 
does not have to pre-approve the complete upper and lower denture (D5110 and D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-
of-network provider. 
 
You asked the Plan to pre-approve physician's services. The Plan denied your request. The Plan says while the 
member is a part of the Plan, they must use network providers to get their medical care and services. The only 
exceptions are emergencies, urgently needed services when the network is not available (generally, when the 
member is out of the area), out-of-area dialysis services and cases in which the Plan authorizes use of out-of-
network providers 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
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 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 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the documentation does support a need for physical 
and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 
program. There is not a reasonable expectation that you 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on March 3, 2021. 
 
You asked the Plan to pay for critical care services. You say that this was billed correctly. The Plan denied 
your request. The Plan says the time spent on this service is not documented. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent on critical 
care services is not documented in the submitted records. Without this information, this code cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) 
provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve  heart rhythm analysis out of network for the enrollee. 
 
You asked the Plan to pre-approve  out of network services. You say that this treatment is medically necessary. 
The Plan denied your request. The Plan says this treatment can be provided in network. 
 
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 provider in this case is not a network provider with the Plan. 
The Plan had network providers available who could have provided the services at issue in this appeal. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pre-approve  heart rhythm analysis out of network for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out of network physician services.  
 
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested 
provider. The Plan denied your request. The Plan says this provider is out of network and you have been 
directed to an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The provider in 
this case is not a network provider with the Plan. The Plan has network providers available who can provide the 
services at issue in this appeal. Therefore, we decided that the Plan does not have to pre-approve out of network 
physician services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the specialist office visit provided on June 7, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you did not know you needed a referral 
from your primary care doctor to see your eye doctor. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the specialist office visit provided on June 7, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria is not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the monitor. Our reviewer says that the 
requested monitor is not medically reasonable or necessary. Our physician reviewer found the record indicates 
that the enrollee has diabetes and uses insulin twice daily. The elements of the coverage criteria are not 
satisfied.  

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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve out-of-network dental care. You say that you were approved for services 
with a network provider but want to see a different dentist because you were dissatisfied with the services 
received from the network provider. The Plan denied your request. The Plan says this provider is not part of the 
Plan's network. Out-of-network dental care is not covered. There are other in-network dental providers who can 
provide the necessary services. 

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 Plan covers supplemental 
preventative and comprehensive services when they are received from a provider in the Plan's specified dental 
network. Out-of-network dental care is not covered.  
 
We looked at the file and Medicare rules. The provider in question is not part of the Plan's dental network. The 
Plan has multiple in-network providers available to provide the requested care. Based on this information, we 
decided that the Plan's rules for coverage of out-of-network dental care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be provided by 
an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that you are severely weakened due to the 
coronavirus. You say that you are not capable of taking care of yourself at home. You say that you cannot stand 
without assistance. You also say that you need these services to be approved. The Plan denied your request. 
The Plan says the provided documentation does not indicate that there has been a changed in function. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that 
the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on April 26, 
2018. 
 
You asked the Plan to pay for full mouth debridement. You say that you should not be liable for this cost. The 
Plan denied your request. The Plan says this service is not covered by your dental benefit in 2018. 
 
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 pay for the full 
mouth debridement (D4355) provided on April 26, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
March 16, 2021. 
 
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 enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 out of network physician services provided to the 
enrollee on March 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services the enrollee requires can safely be received at a different 
setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided February 22, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for psychotherapy services to be covered, there 
must be an attempt to consult the attending or primary care physician.  
 
We looked at the file and Medicare rules. There is no record of any attempt to consult the primary treating 
physician. Based on this information, we decided that Medicare rules for coverage of the psychotherapy 
services have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy 
services (90834) provided February 22, 2021.