Persius/hicric huggingface dataset:
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 LTACH is the appropriate level of care 
for the enrollee. You say the enrollee is medically stable to be transferred to the LTACH at this time. The Plan 
denied your request. The Plan says the LTACH services requested do not meet the requirements for approval. 
 
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. The 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that the 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 that the documentation does not support the medical necessity for admission to an 
IRF due to lack of acute medical complexity, and nursing needs. While the enrollee would benefit from 
physical and occupational therapy the enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72141 provided on June 27, 2022. 
 
You asked the Plan to pay for procedure code 72141. You say that the denied service is coded correctly. The 
Plan denied your request. The Plan says no modifiers are allowed with this code pair. 
 
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, we have confirmed that code 72141 
is a column II code to column I code 72156 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 72141 provided on June 27, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) of the cervical spine (72125) and a 
CT of the lumbar spine (72131). 
 
You asked the Plan to pre-approve a CT of the cervical spine and a CT of the lumbar spine. You say that you 
need these CT scans to see how bad you have progressed, and to find where the pain is coming from. The Plan 
denied your request. The Plan says that you do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT of the cervical spine and a CT of 
the lumbar spine. Our reviewer says that the requested CT scans are reasonable and necessary. Our physician 
reviewer found you have an abnormal neurological exam with absent brachial reflex on the left and right 
quadriceps weakness. Our reviewer also found that these findings represent red flags, and since you cannot 
have an MRI due to your pacer, the requested CT scans, cervical and lumbar spine, should be approved. 
 
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 CT of the cervical spine and a CT of the lumbar spine have been met. 
Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) of the cervical spine 
(72125) and a CT of the lumbar spine (72131).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 heavy-duty power wheelchair with multiple 
power options (K0862) and related accessories and features.  
You asked the Plan to pre-approve a Group 3 heavy-duty power wheelchair and related accessories and 
features. You say that the requested items are a medical necessity for the enrollee. The Plan denied your 
request. The Plan says the requested items are not medically necessary. 
 
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 Group 3 heavy-duty power 
wheelchair and related accessories and features. Our reviewer says that the requested items are not considered 
medically reasonable and necessary in this case. Our physician reviewer found that the enrollee does not use a 
catheter or a ventilator and has no history of skin breakdown. 
 
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 Group 3 heavy-duty power wheelchair and related accessories and features 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 heavy-duty 
power wheelchair with multiple power options (K0862) and related accessories and features.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy services. 
 
You asked the Plan to pre-approve the requested services. You say that the service is medically necessary to 
monitor the enrollee for lymphedema. The Plan denied your request. The Plan says that there is no evidence 
that shows the service improves outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the requested services. Our physician 
reviewer found that the enrollee has a history of a mastectomy and sentinel node biopsy. Bioimpedance 
spectroscopy (BIS) is a more accurate method of identifying which breast cancer survivors will need 
compression intervention compared with tape measurement (TM) to prevent chronic lymphedema, according to 
findings from a study published in Lymphatic Research and Biology. Therefore, the request is medically 
reasonable and 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 been met. Therefore, we decided that the Plan has to 
pre-approve bioimpedance spectroscopy services.  
 
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: 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 you are appealing with supporting 
records. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that 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. 
 
 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: 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 enrollee is very weak and 
tracheostomy dependent. The Plan denied your request. The Plan says based on Medicare guidelines, the 
requested LTACH services do not meet the requirements for approval. 
 
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 that the record indicates that the enrollee remains critically ill and still requires acute 
critical care services. The enrollee continues to receive acute care services, and these have not been denied. The 
medical record does not indicate that the enrollee requires services that she is not currently receiving but that 
would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested 
service cannot be 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the evaluation and programming of an implant device provided on March 16, 2022.
You asked the Plan to reduce the copayment for the evaluation and programming. You say that you were previously charged only a $20 copayment for a specialist visit. The Plan denied your request. The Plan says this cost sharing was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have been asked to pay a $100 copayment for the evaluation and programming. Originally it appeared if you were charged a copayment higher than $100. The Plan has now submitted documentation to confirm you were only asked to pay the $100 copayment for the services you received.
This item/service falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category 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 reduce the copayment for the evaluation and programming of an implant device provided on March 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are willing to participate in the rehabilitation 
program. You would like to return home and be as independent as possible. The Plan denied your request. The 
Plan says the IRF services you are requesting do not meet the requirements for approval. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. While the medical record supports a need for physical or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have not 
been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care 
such as at 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 enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on 
November 22, 2020. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says 
traditional Medicare is responsible for payment of these services. 
 
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 an emergency department visit provided on  
November 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a Freestyle Libre CGM.
You asked the Plan to provide coverage for a Freestyle Libre which you say is medically necessary to keep you off medications. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial for insufficient records. The Plan requested a reopen and provided more records.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees who meet all the required coverage criteria.
Based on the medical records provided you do not meet all five required Medicare criteria. Therefore, we decided that the Plan does not have to provide coverage for a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need further therapy to get back to prior 
mobility and speech skills. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that based on the medical records provided there is no documentation that daily 
skilled services are required. There is no documentation that you require the services on an inpatient basis, only 
in a skilled nursing facility setting. Records do not support that services in the home with home health care or 
in a long-term care facility on a part time basis are not appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 denial should be overturned The Plan 
denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs can be met 
at a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, or at home with 
home health services. 
 
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.  
 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not supported for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Prolia. Our reviewer says that the 
requested use of Prolia is not supported. Our physician reviewer found the record indicates that the enrollee has 
a diagnosis of osteopenia without low traumatic bone fracture. The Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.