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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. 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 respiratory failure and
congestive heart failure. 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, in 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. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
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 must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. 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.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for home health services provided to the enrollee from November 18,
2020, to February 28, 2021. The Plan does not have to pay for March 1, 2021, to March 24, 2021 as that
portion of the case was dismissed.
You asked the Plan to pay for home health services for the enrollee. You say that these services were medically
necessary. The Plan denied your request. The Plan says that Medicare coverage criteria were not met. Maximus
overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and
provided additional information only on the dates of service. The Plan noted the enrollee was no longer a
member of this Plan as of midnight on February 28, 2021 and therefore they would not be required to pay for
March 1, 2021 to March 24, 2021. We should note that with the dates of coverage correction, the Plan did not
address the missing information in the case file.
This case was overturned because the Plan did not make reasonable and diligent efforts to gather and forward
information regarding their decision to deny your request to pay for these services. The Plan did not provide
specific information as to why the facility claim would negate the request for home health reimbursement. It is
the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated.
Therefore, we decided that the Plan is required to pay for the home health aide services provided to the enrollee
from November 18, 2020, to February 28, 2021.
The Plan is not required to pay for March 1, 2021 to March 24, 2021 as the enrollee was not a member of the
Plans for those dates of service.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).
You asked the Plan to pre-approve the dental item. You say that the enrollee needs a partial lower denture. The Plan denied your request. The Plan says 1 lower denture is covered every 5 calendar years. The Plan also says that the frequency limit has been reached.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental item have not been met. Specifically, the frequency limit has been reached. The record shows that the Plan paid for partial lower denture that you received on November 9, 2017. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory pathogen panel provided on May 19, 2020.
You asked the Plan to pay for the respiratory pathogen panel. You say that this should be paid. The Plan denied your request. The Plan says the POS code used is not supported.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the respiratory pathogen panel have not been met.
Therefore, we decided that the Plan does not have to pay for the respiratory pathogen panel provided on May
19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0822).
You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power wheelchair. Our reviewer says that the requested power wheelchair is not medically necessary.
Our physician reviewer found based on the medical records provided there is documentation that the patient's
mobility deficit cannot be helped by the use of a walker or cane, but there is no documentation that the patient's
mobility deficit cannot be helped by the use of a manual wheelchair. Records provided report the patient can
safely self-propel with a manual wheelchair.
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 power wheelchair have not been met. Therefore, we decided that the Plan
does not have to pre-approve a power wheelchair (K0822
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 a Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertilfex device is experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
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 it is felt that the enrollee would benefit from IRF care. The Plan denied your request. The Plan says the requested admission to an IRF 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 the enrollee is a female who was admitted to the hospital due to sepsis from a
diverticular perforation with perihepatic abscess. She has been treated surgically and with intravenous
antibiotics planned through 1/16/22. She suffered a fall while she was in the hospital with a resulting right foot
fracture that has been treated conservatively. The most recent therapy notes indicate that the member is able to
ambulate short distances with a rolling walker and contact guard assistance. She requires assistance with most
self-care tasks and bed mobility.
In this case, the complexity of the member's nursing, medical and rehabilitation needs do not require an acute
rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an
intensive rehabilitation therapy program. There is not a reasonable expectation that this individual will be able
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient
rehabilitation facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) with computed tomography (CT) scan.
You asked the Plan to pre-approve a PET/CT scan. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 a PET/CT scan. Our reviewer says that the services are medically necessary. Our physician reviewer found CMS rules allow for 1 PET/CT scan when there is suspicion of malignancy and since there is still the clinical concern of malignancy despite extensive workup including CT, magnetic resonance imaging (MRI), bone scan and esophagogastroduodenoscopy (EGD) the final test which may provide additional clinical information for appropriate management is PET/CT. CMS rules allow for one such scan if there is clinical suspicion of malignancy and such concern is documented in the records. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET/CT scan have been met. Therefore, we decided that the Plan has to pre-approve a positron emission tomography (PET) with computed tomography (CT) scan.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with congestive heart failure (CHF). From a nursing perspective, the enrollee received oral medications and insulin. The enrollee had stable vital signs. He used oxygen via nasal cannula. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy. The enrollee was at a contact guard to supervision/stand by assist level for functional mobility including gait to 30 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. 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 hip fracture after a fall. 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, in 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. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary, and there is no medical need for it.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there is no documentation that the enrollee's mobility deficit cannot be helped by the use of walker, cane, or manual wheelchair due to the enrollee's level of weakness or instability. Based on the medical records provided, there is no documentation that the enrollee meets Medicare criteria for power tilt and power recline; records do not document the enrollee is high risk for development of skin ulcers (as determined by the Braden Scale score) and the enrollee does not utilize intermittent catheterization for bladder management or have documented spasticity. Therefore the enrollee does not meet Medicare criteria for a group 3 power wheelchair with multiple power options (with power tilt and power recline); the enrollee appears to meet criteria for a group 3 power wheelchair with no power options. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from February 9, 2021, to March 8, 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 there is incorrect and missing home health data.
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 the denied codes is:
G0299:
Direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes
G0300:
Direct skilled nursing services of a licensed practical nurse (lpn) in the home health or hospice setting, each 15
minutes
Q5001:
Hospice or home health care provided in patient's home/residence
We find that the home health claim was not billed correctly in this case. Specifically, a visit was not reported
on February 12, 2021, which is the date that the Q-code was reported on. The episode of care on the claim is
for February 9, 2021, but the first visit on the claim is for February 12, 2021. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan
does not have to pay for home health services provided to the enrollee from February 9, 2021, to March 8,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator.
You asked the Plan to pre-approve an oxygen concentrator. 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 follows Medicare rules. Medicare rules say that certain criteria must be met for recertification. 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 an oxygen concentrator. Our reviewer says that the services are not medically necessary. Our physician reviewer found the latest medical records provided from September 16, 2021 report the enrollee's oxygen saturation on room air was 97%; no recent records are provided documenting an oxygen concentration reading which would meet Medicare criteria for the
requested oxygen concentrator. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve biologic materials to aid in tissue regeneration.
You asked the Plan to pre-approve biologic materials to aid in tissue regeneration. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve biologic materials to aid in tissue regeneration.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your doctor wrote a prescription for shoe inserts and you received a denial letter for them, however due to my back pain, my doctor indicated the shoe inserts are medically necessary, and therefore you believe these items should be covered as a benefit. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.