Persius/hicric huggingface dataset:
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 medically appropriate and 
stable to transfer to a LTACH. The Plan denied your request. The Plan says the patient's care can be managed 
at the current hospital. 
 
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 is currently undergoing treatment at an acute care hospital (ACH) for a 
posterior stroke. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee 
is tolerating ventilator weaning, though it is unclear if complete ventilator liberation and decannulation are 
expected.  There is no evidence that the enrollee requires services that are not currently available. As LTACHs 
and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to 
the LTACH. The enrollee can remain at the current ACH until such time no acute services are required.  The 
enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.  
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 waive the copayment for a specialist visit provided on January 11, 
2022, March 2, 2022, and March 21, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you should not have to pay a 
copayment. The Plan denied your request. The Plan says the copayment applied was 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 a $5 
copayment for Medicare-covered physician specialist services.  
 
You have been asked to pay a $15 copayment for three specialist visits ($5 copayment x 3 visits = $15). A 
specialist visit falls within the Medicare-Covered Physician Specialist 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 specialist visit provided on January 11, 2022, March 2, 2022, and 
March 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from April 20, 2021, through 
April 30, 2021, at DRG 862. 
 
You asked the Plan to pay for inpatient services at DRG 862. You say that the services rendered were 
medically necessary and the clinical documentation supports the reporting of E43. You say that DRG 862 is 
supported and the DRG should remain as originally reported. The Plan denied your request. The Plan says the 
documentation was inconsistent and unclear regarding a diagnosis of severe protein-calorie malnutrition. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with secondary diagnosis code E43, defined as unspecified severe 
protein-calorie malnutrition. 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 inpatient services 
at DRG 862. Our reviewer says that the documentation does not support secondary diagnosis code E43. Our 
physician reviewer found the initial nutrition assessment states a malnutrition evaluation could not be 
completed, and the registered dietitian was unable to evaluate fat loss or muscle loss.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from April 20, 2021, through April 30, 2021, at DRG 862.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that facet injections are 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. Magnetic resonance imaging (MRI) shows multiple pain generators. He has not had an epidural steroid 
injection. The criteria for coverage are not met and the services are not medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injections.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide. 
 
You asked the Plan to pre-approve a home health aide. You say that you need someone to help you shower 
from the waist down because you cannot bend down. You say that your feet get swollen and your back pain is 
very intense due to a disc problem and you need to have someone to help you clean and do shopping. The Plan 
denied your request. The Plan says you do not meet the Medicare coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 health aide. Our reviewer says 
that a home health aide is not medically necessary. Our physician reviewer found that while you do require 
assistance with bathing/grooming and some Instrumental Activities of Daily Living (IADLs) secondary to your 
moderate-severe back pain, you do not meet the criteria for HHA services. Your current needs could be met with a lower level of services such as Personal Care (agency) with homemaker services. The review has 
determined that the services do not meet the definition of home health aide services as per Medicare. The home 
health aide services are not reasonable and necessary to the treatment of your illness or injury by the skilled 
professional staff. 
 
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 health aide have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home health aide.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity angiography and revascularization of 
the iliac artery. 
 
You asked the Plan to pre-approve lower extremity angiography and revascularization of the iliac artery. You 
say that the requested procedure is medically necessary and needs to be done as soon as possible due to the 
enrollee's stenosis. The Plan denied your request. The Plan says the requested services are not medically 
necessary because there is no documentation of leg pain with walking, resulting in an inability to perform 
normal work or other activities that are important to the enrollee. The Plan says that the records do not show 
that the enrollee has competed exercise therapy to treat their 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 lower extremity angiography and 
revascularization of the iliac artery. Our reviewer says that lower extremity angiography and revascularization 
of the iliac artery is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has a history of peripheral arterial ultrasound examination of the legs in June of 2022, with 
no significant stenosis in the iliac, femoral or popliteal arteries. An office visit in July of 2022 indicated that leg pulses were normal, and there is no reference to leg symptoms. There is insufficient documentation to support 
the medical necessity for angiography and revascularization of the iliac artery in this enrollees clinical 
management 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower extremity angiography and revascularization of the iliac artery have not 
been met. Therefore, we decided that the Plan does not have to pre-approve lower extremity angiography and 
revascularization of the iliac artery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig for the enrollee. 
 
You asked the Plan to pre-approve a wig. You say that a wig is medically necessary. The Plan denied your 
request. The Plan says a wig is not covered by Medicare or the Plan. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig for the 
enrollee.
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 orthotics are necessary for foot pain. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model 
without calibrated gradient pressure (E0651) and a segmental pneumatic appliance for use with pneumatic 
compressor to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and a segmental pneumatic appliance. You say that 
you would like reconsideration for the requested procedure. The Plan denied your request. The Plan says you 
must use network providers to get your medical care and services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and a segmental 
pneumatic appliance for use with pneumatic compressor to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital for bacterial endocarditis. He is now medically stable with no complex nursing or rehabilitation needs. 
He 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. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve the power scooter. You say that your legs are getting weaker and you really 
need the scooter. The Plan denied your request. The Plan says the enrollee does not meet the criteria as she 
does not have access to enter/exit home and does not have a secure area to store and charge the POV when not 
being used. 
 
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 patients 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 scooter. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Per Medicare criteria as the device must be necessary to perform mobility related 
activities of daily living. The enrollee is independent in activities of daily living. She ambulates in the home. 
 
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 scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the power operated vehicle, group 1 standard, patient weight capacity up to and 
including 300 pounds (K0800).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Skilled Nursing Facility (SNF) care on 
November 22, 2021, to December 01, 2021. 
 
You asked the Plan to waive the copayment for Skilled Nursing Facility (SNF) care. You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says the cost sharing you are being 
charged 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 a $0 per 
day, days 1-20; $178 per day, days 21-100 for each SNF stay. A benefit period begins the day you go into a 
hospital or skilled nursing facility. The benefit period ends when you havent received any inpatient hospital 
care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after 
one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods 
you can have. There were 5 days, for days 21-100. $178 x 5 = $890. Therefore, results in the total cost sharing 
amount of $890.  You have been asked to pay a $178 copayment for each day of Skilled Nursing Facility (SNF) care. Skilled 
Nursing Facility (SNF) care falls within the Skilled Nursing Facility (SNF) care 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 Skilled Nursing Facility (SNF) care on November 22, 2021, to 
December 01, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator 
provided on January 3, 2022. 
 
You asked the Plan to waive the coinsurance for an automatic external defibrillator. You say that you did not 
want this item to begin with and were burned by it. Due to this issue, you feel like you should not need to pay 
this coinsurance. The Plan denied your request. The Plan says the coinsurance applied was 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 a 20% 
coinsurance for Medicare-covered durable medical equipment (DME). The allowed amount of this item is 
$3,080.95 resulting in a coinsurance amount of $616.19 ($3,080.95 x 20% = $616.19). 
 
You have been asked to pay a $616.19 coinsurance for an automatic external defibrillator. An automatic 
external defibrillator falls within the Medicare-covered Durable Medical Equipment (DME) 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 coinsurance for an automatic external 
defibrillator provided on January 3, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review. 
 
Your complaint about inadequate customer service is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Baroreflex stimulation device. 
 
You asked the Plan to pre-approve the Baroreflex stimulation device. You say that the Baroreflex stimulation 
device is medically necessary. The Plan denied your request. The Plan says carotid sinus baroreflex activation 
is considered experimental, investigational and/or unproven. 
 
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 Baroreflex stimulation device. Our 
reviewer says that the Baroreflex stimulation device is not considered medically reasonable and necessary. Our 
physician reviewer found Baroreflex stimulation devices provide electrical stimulation of the baroreceptors in 
the carotid arteries using an implanted device. Activation of the baroreflex inhibits the sympathetic nervous 
system, resulting in various physiologic changes, including slowed heart rate and lower blood pressure. Carotid 
sinus baroreflex activation is considered experimental, investigational and/or unproven. It is unknown if carotid 
sinus baroreflex activation improves health outcomes or patient management. In addition, patient selection 
criteria have not been adequately defined. At this time, clinical studies have not definitively established that 
carotid sinus baroreflex activation is more effective than established alternatives. 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 Baroreflex stimulation device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Baroreflex stimulation device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 23, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 76705 billed for date of service March 23, 2022.