Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided the Plan has to pay for the Cerebral perfusion analysis using computed tomography (0042T) provided on May 6, 2022.
You asked the Plan to pay this claim as billed. The Plan denied your request. The Plan says that based on the Medicare Local Coverage Article (LCA) A56902 for Billing and Coding: Category III Codes, the enrollee's diagnosis does not meet the required criteria. Maximus overturned the Plans denial using Medicare Local Coverage Determination (LCD) Category III Codes (L35490). The Plan requested a reopen and stated Maximus did not apply the correct criteria.
Both Maximus and the Plan were incorrect in the application of law on their original decisions. The enrollee lives in a state, and the testing was performed, based on the records provided. Neither of these states have a MAC-Part B jurisdiction designation for LCA A56902 or LCD L35490. Both states only list a MAC-Part A jurisdiction, which does not apply in this case. Therefore, this testing should have been reviewed under the medical necessity rule Social Security Act, Section 1862(a)(1)(A), which gives a broader designation for coverage. We asked our physician reviewer to carefully review the case file. Our physician reviewer found that the enrollee had Cerebral perfusion analysis using computed tomography (CT). The enrollee had acute aphasia. The stroke protocol was initiated. A CT perfusion was requested due to clinical symptoms. In this case, the use of CT perfusion to determine the presence of penumbra or if the brain was at risk for ischemia is considered standard practice in stroke protocols. Medical necessity was therefore established.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for payment of this claim have been met. Therefore, we decided that the Plan has to pay for the Cerebral perfusion analysis using computed tomography (0042T) provided on May 6, 2022.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for lab services provided on June 2, 2022.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says that these services are not covered by Medicare. Maximus upheld the
Plans denial. Maximus then reopened the case after discovering an error.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules. You were referred for these services by a contract provider. The file does not
show that the Plan provided notice that these services would not be covered. Under Medicare rules, this means
these services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for lab
services provided on June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on March 30, 2022, and billed under Claim A.
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing 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. The Plan notes that this claim was for application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part there-of.
The claim denied because the provider did not bill the correct code for the area that was treated. Code 15272 has a maximum unit value of 3 units per date of service. The claim history shows 3 units of Code 15272-58 was processed as enrollee responsibility due to no referral.
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 medical records provided are not supported by the services billed. Medicare rules for coverage of this claim. have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on March 30, 2022, and billed under Claim A.
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 SNF care will help the enrollee reach maximum 
function. The Plan denied your request. The Plan says the denial of SNF care is correct. 
 
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 the requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary and mandibular denture (D5110, D5120) 
provided on November 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 30, 2018. 
Therefore, we decided that the Plan does not have to pay for a maxillary and mandibular denture (D5110, 
D5120) provided on November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued authorization for a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is diagnosed with chronic 
obstructive pulmonary disease and chronic respiratory failure. She is using the Life2000 with favorable 
outcomes and has been for nearly 2 years. She said since she started the Life 2000 she is "not afraid of not 
waking up in the morning". The Plan denied your request. The Plan says to be reasonable and necessary, an 
item or service must not be investigational or experimental. An item or service must be at least as effective as 
standard medical care. However, it should not be more than is necessary. A review of the current medical 
literature does not consider this device to be standard medical treatment for the patient's condition. The 
Life2000 system is not a true ventilator because it is not capable of manually adjusting the amount of air (tidal 
volume ventilatory support) that is ordered by your treating provider. It is designed primarily for use during 
activity. There is insufficient evidence of benefit in the treatment of chronic obstructive pulmonary disease. 
The request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 
 
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 home ventilator. Our reviewer says that while the enrollee has evidence of chronic respiratory failure secondary to chronic obstructive pulmonary disease, it is not documented that BiPAP with a back-up rate or volume-assured pressure support have been utilized and failed. Products classified as E0466 when used to provide CPAP or bi-level PAP are not covered.
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued authorization for a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture and 
interpretation (D0367), consultation (D9310), and therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve a cone beam CT capture and interpretation, consultation, and therapeutic 
parenteral drugs. You say that you believe these services should be covered with your insurance. The Plan 
denied your request. The Plan says cone beam CT capture and interpretation and therapeutic parenteral drugs 
are not covered on your plan. The Plan also says that you are over the age limit for a consultation to be 
covered. 
 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 cone beam CT capture and 
interpretation and therapeutic parenteral drugs are not among those covered under this benefit. The contract 
also clearly states that you must be between the ages of 0 and 20 to be approved for a consultation. The record 
shows that you are over the age limit for a consultation, and this service cannot be approved. Therefore, we 
decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture and 
interpretation (D0367), consultation (D9310), and therapeutic parenteral drugs (D9612).
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 cannot go home by herself as a result of 
her stroke. The enrollee needs the rehabilitation to regain as much functionality as possible. The Plan denied 
your request. The Plan says he IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility. 
 
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 was admitted for a stroke. The enrollee's medical problems are stable, 
and there are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the 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: 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility. 
 
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 was admitted for surgical management of volvulus. The enrollee's medical problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the 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: 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 IRF care is needed for the enrollee to return to 
being independent and would prefer an intense rehabilitation program. The Plan denied your request. The Plan 
says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower level of care such 
as a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 cannot fully participate in rehabilitation at her current weight bearing 
status. The enrollee is limited in her participation in rehabilitation. The enrollee does not require intensive 
rehabilitation to recover from an ankle fracture. 
 
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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you believe you need more medical care 
than what you would receive in a skilled nursing facility. The Plan denied your request. The Plan says you are 
receiving appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. All medically necessary care is being provided in the current 
acute care setting. There are no services available at the LTACH that you require that are not available at the 
health care setting being offered by the health plan. The health plan has approved ongoing care in the current 
acute care 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for (D9910) application of desensitizing medicament and 
(D0350) 2D oral/facial photographic image provided on November 7, 2022. 
 
You asked the Plan to pay for dental services. You say that this should be covered. The Plan denied your 
request. The Plan says these are not covered services. 
 
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 (D9910) 
application of desensitizing medicament and (D0350) 2D oral/facial photographic image provided on 
November 7, 2022.
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 medically necessary to 
provide all medical needs, along with aggressive therapy for the enrollee. The Plan denied your request. The 
Plan says they will continue to cover medically necessary acute and critical care at the current facility until the 
enrollee's condition is stable for transfer to an alternate level of care. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care 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 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve SSBCI benefits. 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says that you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the plan did not send us medical records. You say that you should 
be eligible for SSBCI benefits due to your health issues. Without medical records, we cannot determine 
whether or not you are eligible for the benefits. Therefore, the Plan has to pre-approve SSBCI benefits.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve yttrium-90 (Y-90) radioembolization services. 
 
You asked the Plan to pre-approve the requested services. You say that there are limited effective treatment 
options for the enrollee's condition. The Plan denied your request. The Plan says there is not enough evidence 
that this is useful for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that radioembolization is medically necessary for non-colorectal cancer liver metastases when 
no other acceptable standard therapy is available, or no other therapy is likely to be effective (i.e., chemo-
resistant tumors). However, in this case, there is no documentation for why systemic therapy is not being 
considered, nor resection, or much less invasive external beam radiation. Therefore, the requested services are 
not considered medically reasonable or 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 yttrium-90 (Y-90) radioembolization services.