Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs the services of an IRF because without admission it would seriously jeopardize their life or health and it would seriously jeopardize their ability to regain maximum function and it is medically necessary. The Plan denied your request. The Plan says the enrollee can safely receive the services you need in other settings, for example: 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 was admitted to an acute hospital with MS that is getting worse with frequent falls. More weakness in RLE that was affected by MS. MRI showed no new lesions. Per neurology, no change in the LE weakness. Treated with Solumedrol. Noted to be diabetic uncontrolled with polyneuropathy and UTI. High blood glucose attributed to steroids. Stable medically and comorbid conditions are all stable. PMH: Obesity, MS, HLD, and HTN.

Therapy notes reviewed. Needs SBA for bed mobility, transfers with min to mod A of 2. Needs assist for LB ADLs otherwise rest are all independent. PT and OT recommending SNF rehab. On review of the available records, the enrollee with MS with no acute exacerbation, as described above, does not meet CMS coverage criteria for IRF admission.

The enrollee is medically stable and does not need PM&R physician's supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee needs routine PT and OT and does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. IRF admission is not medically necessary based on lack of medical complexity, lack of rehab nursing needs.

Documents does not support the medical necessity for admission to an IRF. The enrollee's rehab needs can be safely provided in a lower intensity and alternate setting such as in an SNF.

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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA), 
multiple organisms (87801), infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified 
(87798), infectious agent detection by nucleic acid (DNA or RNA) (87481) provided on January 13, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that for review and reconsideration you are 
including a copy of the medical records that will show the medical necessity of the services rendered. The Plan 
denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers 
require prior authorization before services being rendered. 
 
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 infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms (87801), infectious agent detection by nucleic acid (DNA or RNA), not otherwise 
specified (87798), infectious agent detection by nucleic acid (DNA or RNA) (87481) provided on January 13, 
2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the IRF services provided from October 13, 2021, through 
October 20, 2021. 
  You asked the Plan to pay for IRF care. You say that services provided were medically necessary. The Plan 
denied your request. The Plan says the services can be safely received at a different setting such as a skilled 
nursing facility, home health services or 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 pay for 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. While the enrollee has a need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pay for the IRF services provided from October 13, 2021, through October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cytopathology, in situ hybridization provided to the enrollee 
on September 22, 2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the results from this test are intended for use, in conjunction with and not in lieu of 
current standard diagnostic procedures, as an aid for initial diagnosis of bladder carcinoma in patients with 
hematuria and subsequent monitoring for tumor recurrence in patients previously diagnosed with bladder 
cancer. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee does not meet the coverage criteria for this test. The test is not being used according to the 
FDA label. Urovysion FISH testing is not considered a screening test for urothelial cancer. Cystoscopy, 
ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of 
Urovysion FISH testing. Urinary biomarker tests such as Urovysion FISH testing give significant false-
negative results in patients with urothelial cancer and are subject to false-positive results in others. Accuracy is 
poor for low-stage and low-grade tumors.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for cytopathology, in situ hybridization provided to the enrollee on September 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation you will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. You have unilateral 
primary osteoarthritis of the left hip. Total hip arthroplasty has been approved. The provided note did not reveal 
that you are at a high risk of complication or with an unstable condition and you have passed preoperative 
clearance evaluation. There is not expectation that you would require hospital services that would likely cross 2 
midnights for this typically ambulatory procedure. Our physician reviewer found that your condition does not 
meet criteria for coverage of inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all-lower extremity prostheses, multi-axial rotation 
unit ('mcp' or equal) (L5986) all lower extremity prostheses, flex foot system (L5980) addition, endoskeletal 
system, above knee, flexible protective outer surface covering system (L5964). 
 You asked the Plan to pre-approve advanced foot and knee with ankle rotational unit and prosthetic leg cover. 
You say that the enrollee's practitioner and prosthetic specialist consider the enrollee a K3 level ambulator. A 
mechanical knee and simple foot would not be safe for this enrollee. The Plan denied your request. The Plan 
says the request for K3 foot and knee exceeds the enrollee's need and does not meet Medicare criteria as 
reasonable and necessary. The enrollee is not exposed to harsh wet environment to meet for an extra protective 
cover. 
 
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 advanced foot and knee with ankle 
rotational unit and prosthetic leg cover. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 68 year old 
male with acquired absence of the right leg above the knee. Per the documentation the enrollee does not appear 
to function at a K3 level. The enrollee is not exposed to a harsh wet environment to meet for an extra protective 
cover. The review has determined that the requested items/services at issue in this case do not meet the 
medically reasonable or necessary criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of advanced foot and knee with ankle rotational unit and prosthetic leg cover have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an all-lower extremity 
prostheses, multi-axial rotation unit ('mcp' or equal) (L5986) all lower extremity prostheses, flex foot system 
(L5980) addition, endoskeletal system, above knee, flexible protective outer surface covering system (L5964).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation you will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. You are undergoing a 
planned elective left knee surgery. You are medically stable and have been cleared for the elective procedure. 
The planned procedure is not listed on the Inpatient Only List. The procedure is currently approved as an 
ambulatory procedure. There is no documentation provided to support the expectation you will require a 
greater than 2 midnight stay. Our physician reviewer found that your condition does not meet criteria for 
coverage of inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ViviGen Allograft. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the clinical value and effectiveness of the ViviGen Allograft in the setting of 
spinal fusion surgery has not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for your pathology. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Our physician reviewer found that your condition 
does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ViviGen Allograft.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic x-rays (D0330) and upper partial denture (D5213) 
provided October 4, 2021 to November 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are wondering if there would be any 
financial help for the dental work that she had done. The Plan denied your request. The Plan says these services 
are not covered under the Plan benefits. 
 
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 
panoramic x-rays (D0330) and upper partial denture (D5213) provided October 4, 2021 to November 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided from November 11, 2021, 
through November 29, 2021. 
 
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says the 
member does not have out of network benefits under this Plan. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physical therapy services provided from November 11, 2021, 
through November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on December 8, 2021. 
 
You asked the Plan to reimburse you for the hearing aids. You say that you were unaware that the enrollee 
could only go to specific providers. The Plan denied your request. The Plan says you must use a network 
hearing provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when received from a network hearing or hearing aid provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not received from a 
network hearing or hearing aid provider. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse 
you for hearing aids provided on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection procedure (51600) provided on September 21, 2021. 
 
You asked the Plan to pay for an injection procedure. You say that this is supported in the records. The Plan 
denied your request. The Plan says this is not documented. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 51600 is injection procedure for cystography or voiding 
urethrocystography. 
 
We find that CPT code 51600 is not supported in the medical record. Specifically, the records do not include 
documentation of an injection being provided. Based on this information, we decided that Medicare rules for coverage of an injection procedure have not been met. Therefore, we decided that the Plan does not have to pay 
for an injection procedure (51600) provided on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided on 
February 24, 2022. 
 
You asked the Plan to pay for the dental service. You say that this service was necessary to extract your tooth. 
The Plan denied your request. The Plan says fixed partial denture sectioning is not listed as a covered service. 
 
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 fixed partial denture sectioning is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
fixed partial denture sectioning (D9120) provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit billed to the enrollee for November 15, 2021,
under code 99214.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says this visit falls under the global surgery code. Maximus overturned the Plans denial
because proof of payment for the surgery had not been provided. The Plan requested a reopen and provided the
required information.
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. Medicare defines the
global period as that period during which a physician may not bill for related office visits. According to
Medicare, a major surgery has a global period of 90 days. In this case, the records show the enrollee had major
surgery on August 25, 2021. The office visit for November 15, 2021, falls within the global payment period
after the procedure. Medicare rules for coverage of this service have not been met. Therefore, we decided that
the Plan does not have to pay for an office visit billed to the enrollee for November 15, 2021, under code 99214.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of x-rays (D0330), and a comprehensive 
oral evaluation (D0150), provided by a participating provider on February 10, 2022. 
 
You asked the Plan to pay for a complete series of x-rays and a comprehensive oral evaluation. You say that 
the Plan should pay for this. The Plan denied your request. The Plan says the benefit limit for the rendered 
services have already been met and exhausted. 
 
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 one complete 
series of x-rays every five years, and one comprehensive oral evaluation every three years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0330 and D0150 was 
previously provided on August 19, 2020. Based on this information, we decided that the Plan's rules for 
coverage of a complete series of x-rays and a comprehensive oral evaluation have not been met. Therefore, we 
decided that the Plan does not have to pay for a complete series of x-rays (D0330), and a comprehensive oral 
evaluation (D0150), provided by a participating provider on February 10, 2022.