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 the enrollee meets Medicare criteria for 
LTACH services that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan 
says that LTACH is not medically necessary. The enrollee can safely receive the care they need in the hospital, 
if approved by the health plan. 
 
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 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 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. You say that this will provide the best outcome so that your heart 
can stay stable. The Plan denied your request. The Plan says the request is not medically necessary, the services 
you need can be provided safely in other settings. 
 
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. 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve special supplemental benefits for the chronically ill (SSBCI). 
 
You asked the Plan to pre-approve the benefits. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requirements are not met for the SSBCI program. 
 
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. The plan has not substantiated their denial in this case. The plan says in their 
denial - "per attestation submitted by the provider, member does not have a need for intensive care 
management, is a high risk for hospitalization with diagnosis of CAD, cardiovascular disorders, dementia, and 
neurologic disorders; therefore, member does not require the requirements for the SSBCI program." This denial 
cannot be verified as this attestation submitted by the provider was not provided for review to MAXIMUS. 
There are no medical records or diagnosis information to verify if the enrollee has a covered chronic condition 
or is a high risk for hospitalization with a need for intensive case management. The plan needs to verify and substantiate their denial in this case. Therefore, we decided that the Plan has to pre-approve special 
supplemental benefits for the chronically ill (SSBCI).  
 
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 pay for a home visit provided on November 15, 2021, by an OON 
provider. 
 
You asked the Plan to pay for a home visit. You say to please review the supporting documentation as the 
services have been deemed payable. The Plan denied your request. The Plan says the out-of-network services 
were not authorized. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home visit provided on November 15, 2021, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on March 3, 2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports medical necessity. 
The Plan denied your request. The Plan says the claim exceeded the medically unlikely edits. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We find that 17 units of CPT code 88341 were billed. The Plan has agreed to pay for 13 units. The records do 
not include the pathology report to show that additional units were provided and/or medically reasonable and 
necessary. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the pathology services provided on March 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve polysomnography testing (sleep study). 
 
You asked the Plan to pre-approve polysomnography. You say that you have had sleep studies which were 
inconclusive. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because you already had a normal polysomnography test. 
 
The Plan follows Medicare rules. Medicare rules state that polysomnography may be used to evaluate certain 
conditions. 
 
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 polysomnography. Our reviewer says 
that you do not meet the Medicare criteria for polysomnography testing. Our physician reviewer found you 
have a diagnosis of hypersomnia. The record indicates that you underwent polysomnography on May 19, 2022 
which was normal, with no equipment failure. There was no indication that you could not sleep or slept for an 
insufficient amount of time. The results were not inconclusive. Your treating provider is not initiating therapy 
or confirming the efficacy of prescribed therapy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of polysomnography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve polysomnography testing (sleep study).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #18 (D2740). We also decided that the Plan does 
not have to pre-approve core build up on tooth #18 (D2950).  
 
You asked the Plan to pre-approve a crown and core build up. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no evidence of decay or missing crown to 
support the need for replacement. The Plan also says that core build up (D2950) is not covered by your dental 
benefits. 
 We decided that the Plan has to pre-approve a crown on tooth #18 (D2740).  
 
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. The Plan covers a crown when 
the services are medically necessary and reasonable. 
 
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 crown. Our reviewer says that the 
coverage criteria has been met. Our physician reviewer found that the documentation provided meets the 
criteria for coverage for a replacement crown (D2740) on tooth #18 due to the open mesial margin and 
recurrent caries. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have been met. Therefore, we decided that the Plan has to pre-approve 
a crown on tooth #18 (D2740).  
 
We also decided that the Plan does not have to pre-approve core build up on tooth #18 (D2950). 
 
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, core build up is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up on 
tooth #18 (D2950). 
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve percutaneous neurostimulator implantation. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that percutaneous neurostimulator implantation is 
covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has chronic low back pain and 
radicular signs. She has had physical therapy, home exercise, ice, rest, heat, and an epidural steroid injection. 
She has psychological clearance. Magnetic resonance imaging (MRI) shows arachnoiditis of the nerve roots. 
The criteria for coverage are met and the services are therefore reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve percutaneous neurostimulator implantation.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that enrollee's is in need for LTACH for 25-
30 days as they will require a multidisciplinary team to include daily physician assessment and intervention. 
You say that the enrollee has failed lower level of care at home with home health and requires very close 
monitoring. The Plan denied your request. The Plan says the enrollee does not require LTACH services. The 
enrollees current medical plan needs can be met in their current setting. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
where he/she is currently receiving 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment billed for May 14, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that the medical records show medical 
necessity. The Plan denied your request. The Plan says the documentation does not match the date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the billed date of service. Based on this information, 
we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does 
not have to pay for the durable medical equipment billed for May 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine polymerase chain reaction (PCR) panel testing 
provided on April 1, 2022. 
 
You asked the Plan to pay for the PCR panel testing. You say that the services in dispute were medically 
necessary. The Plan denied your request. The Plan says the standard of care for the evaluation of urinary 
incontinence is urinalysis with urine culture and sensitivity. The Plan says that the PCR testing is considered 
unproven and not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that urine cultures are only covered for certain medical 
indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the PCR panel testing. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the case file does not contain clinical documentation that the enrollees urinalysis is abnormal suggesting urinary tract infection, or that the 
enrollee has clinical signs and symptoms indicative of a possible urinary tract infection, or is being evaluated 
for suspected urosepsis, fever of unknown origin, or other systemic manifestations of infection without a 
known source. 
 
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 PCR panel testing have not been met. Therefore, we decided that the Plan 
does not have to pay for urine polymerase chain reaction (PCR) panel testing provided on April 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested use of this drug is not approved by the 
FDA. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 drug, Prolia, is not medically necessary. Our physician reviewer found the requested use of Prolia is 
not Food and Drug Administration (FDA)-approved for the enrollee's diagnosis. The reviewer found that the 
requested use is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. Therefore, the reviewer found that the requested use of Prolia in this situation 
is not 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
provided on May 9, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that all codes on this claim should have 
been paid. The Plan denied your request. The Plan says this service does not qualify for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by 
the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) provided on 
May 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service February 9, 
2022. 
 
You asked the Plan to pay for procedure code 76775. You say that the procedure code was not bundled with 
any other code. The Plan denied your request. The Plan says payment for code 76775 is bundled into payment 
for code 93978. 
 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 76775 is a column II code to column I code 93978. 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 76775 
billed for date of service February 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70455 billed for date of service May 19, 
2022. 
 You asked the Plan to pay for procedure code 70455. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70455 is bundled into payment for 
code 70551. 
 
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 70455 
is a column II code to column I code 70551. 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 70455 billed for date of service May 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours of home health aide (HHA) services 
(T1021). 
 
You asked the Plan to pre-approve additional hours of HHA services. The Plan denied your request. The Plan 
says the additional hours requested is considered custodial care and personal care instead of a medical need. 
 
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 additional hours of HHA services. Our 
reviewer says that 20 hrs per week of HHA services is not medically necessary. Our physician reviewer found 
clinical documentation shows that HHA services are necessary for implementation of treatment plan, however, 
there is no documented clinical change to justify an increase in HHA 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 additional hours of HHA services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional hours of home health aide (HHA) services (T1021).