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. The Plan denied your request. The Plan says the enrollee is not 
able to tolerate at least three hours of therapy a day. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for lumbar surgery. His medical problems are stable. 
There is not a reasonable expectation that he will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. While the medical record supports 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. 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
October 1, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
October 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 transfer to LTACH is not medically necessary at this time as the enrollee is not yet 
stable for transfer and as it would not be clinically advantageous. Completion of treatment at the current facility 
is recommended. 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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided from June 24, 2021, to December 30, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the ambulance services were medically 
necessary. The Plan denied your request. The Plan says the provided documentation does not indicate that the 
enrollee was bedridden on the dates of service in this case. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 ambulance services. Our reviewer says 
that the ambulance services are not medically necessary. Our physician reviewer found the documentation did 
not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type 
of vehicle) were contraindicated for the enrollee for the dates of service in this case.  
 The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-
sustaining equipment that only a fully equipped ambulance can provide for safe transport for the dates of 
service in this case. The documentation did not support that the ambulance transports in this case were 
medically reasonable and necessary 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 the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and 
ground mileage (A0425) provided from June 24, 2021, to December 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this procedure is considered investigational or experimental. 
 
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 requested services are not considered medically reasonable and necessary in this case. The intracept 
procedure is experimental. More research is needed. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 19, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the test was ordered by in-network physician to 
evaluate and determine effective treatment planning for your member. The Plan denied your request. The Plan 
says this provider is not a network provider with the Plan. The Plan also says that the services were not 
authorized by a network or primary care provider. The Plan also says that they have 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 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 laboratory services provided on October 19, 2021, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for echocardiography provided on January 20, 
2022. 
 
You asked the Plan to waive the copayment for echocardiography. You say that you are on a fixed income and 
cannot afford this bill. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $250 
copayment for each covered diagnostic procedure or test at a network outpatient facility. 
 
You have been asked to pay $250 copayment for Echocardiography. Echocardiography 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 copayment for echocardiography provided on January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression wraps (A6545). 
 
You asked the Plan to pre-approve gradient compression wraps. The Plan denied your request. The Plan says 
your chronic ulcerations are not surgically created, modified or debrided, and do not fit criteria as qualifying 
wounds for compression wrap coverage under Medicare. 
 
The Plan follows Medicare rules. Medicare rules say that surgical dressings are covered when a qualifying 
wound is present. 
 
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 gradient compression wraps. Our 
reviewer says that the criteria for the requested gradient compression wraps has not been met. Our physician 
reviewer found as your chronic ulcerations are not surgically created, modified or debrided, they do not fit 
criteria as qualifying wounds for compression wrap coverage under Medicare. The review has determined that 
the compression wrap at appeal is to be used as a primary or secondary dressing over wounds, and does not 
meet the statutory requirements for a qualifying wound (surgically created or modified, or debrided). Our 
reviewer also found that you do not have a qualified wound that the compression wrap will be used for. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of gradient compression wraps have not been met. Therefore, we decided that the 
Plan does not have to pre-approve gradient compression wraps (A6545).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the current device provided is 
too heavy. The Plan denied your request. The Plan says this request is considered a duplicate as the enrollee 
already has portable oxygen systems that meets the defined medical need of support during activities of daily 
living in and around the home. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a portable oxygen concentrator (Inogen G3 weight 4.8) and an oxygen conserving 
device with ML6 tanks. The portable oxygen concentrator (Inogen G3 weight 4.8) and an oxygen conserving 
device with ML6 tanks serves the same purpose as the requested portable oxygen concentrator. Therefore, we 
decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Caris Molecular Intelligence MI Profile and Caris GPSai 
testing rendered on January 18, 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 services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of malignant 
desmoplastic melanoma of the scalp with adjacent lytic/destructive calvarial exension. The enrollee was 
deemed not a good candidate for surgery. External beam radiation treatment was offered. The documentation 
does not support that the testing at issue in this case has an Food and Drug Administration (FDA)-approved or 
FDA-cleared indication for use in the enrollee's cancer. The documentation does not support that the testing in 
this case was medically reasonable and necessary for the enrollee in this case. 
 
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 pay for the Caris Molecular Intelligence MI Profile and Caris GPSai testing rendered on January 18, 
2022.  
 
Local Coverage Determination (LCD) L36256 referenced by the Plan does not provide coverage criteria for the 
services at issue and was not used in the MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office or other outpatient visit (code 99204) 
provided on October 15, 2021. 
 
You asked the Plan to pay for a new patient office or other outpatient visit. The Plan denied your request. The 
Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on November 11, 2021. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for a new patient office or other outpatient visit have not been 
met. Therefore, we decided that the Plan does not have to pay for a new patient office or other outpatient visit 
(code 99204) provided on October 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fully electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a fully electric 
hospital bed.
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 demonstrating slow but steady 
functional gains. The Plan denied your request. The Plan says the enrollee is not expected to participate in three 
hours of therapy per day. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for normal pressure hydrocephalus. His medical 
problems are stable.  There is not a reasonable expectation that he will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methotrexate (J9260) and vincristine sulfate (J9370). 
 
You asked the Plan to pre-approve the chemotherapy drugs. You say that the requested drugs are medically 
necessary. The Plan denied your request. The Plan says the requested drugs are considered a routine cost for 
the clinical trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the chemotherapy drugs as part of a clinical trial. The Plan does 
not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not 
have to pre-approve methotrexate (J9260) and vincristine sulfate (J9370).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92004) 
provided on December 8, 2021. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that you were told there 
would be no cost. The Plan denied your request. The Plan says the copayment was applied 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 $20 
copayment for an eye examination to diagnose and treat diseases and conditions of the eye.  
 
 
 
 
 
 You have been asked to pay a $20 copayment for a medical eye examination. The service at issue falls within 
vision 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 a medical eye examination 
(92004) provided on December 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of 76881-RT and two units of 76881-LT billed for 
date of service December 1, 2021. 
 
You asked the Plan to pay for four units of 76881. You say that these ultrasounds were medically necessary 
and were provided for the left and right groin as well as the left and right axilla. The Plan denied your request. 
The Plan says these services were not reported in accordance with Medicare billing regulations. 
 
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 76881 is ultrasound, complete joint (i.e., joint space and 
peri-articular soft-tissue structures), real-time with image documentation. 
 
We asked our coder 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 four units of 76881. Our reviewer says that these services are 
not supported as billed. Our reviewer found chat CPT code requires ultrasound examination of all of the 
following joint elements: joint space (e.g., effusion, peri-articular soft-tissue structures that surround the joint 
(i.e., muscles, tendons, other soft-tissue structures), and any identifiable abnormality.  In some circumstances, additional evaluations such as dynamic imaging or stress maneuvers may be performed as part of the complete 
evaluation. This code also requires permanently recorded images and a written report containing a description 
of each of the required elements or reason that an element(s) could not be visualized. When fewer than all of 
the required elements for a "complete" exam (76881) are performed, report the "limited" code. 
 
The procedure report and documentation do not support a complete joint ultrasound with real-time with image 
documentation. The units of service would be per joint; however, CPT 76881 is an incorrect code to report for 
services documented.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of four units of 76881 have not been met. Therefore, we decided that the Plan does 
not have to pay for two units of 76881-RT and two units of 76881-LT billed for date of service December 1, 
2021.