Persius/hicric huggingface dataset:
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 it is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee does not meet all of the requirements. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a fibula fracture after a fall. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. There is not a reasonable expectation that this 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that medical records were provided. The Plan denied 
your request. The Plan says the facility must be enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on August 25, 2022.
You asked the Plan to waive the deductible for the office visit. You say that this was an annual wellness 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. Your contract with the Plan says that there is an $800 deductible which applies to covered medical services. The item or service you asked the Plan to waive the deductible for falls within the covered medical services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is an $800 deductible which applies to covered medical services.
This cost sharing is a contractual obligation that had not been met at the time the office visit was received on August 25, 2022. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on August 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional occupational therapy visits. 
 
You asked the Plan to pre-approve occupational therapy visits. You say that the enrollee would like 
reconsideration because the services are medically necessary. The Plan denied your request. The Plan says 12 
additional occupational therapy visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 occupational therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee is receiving a repetitive exercise 
program for a chronic condition and has functional capacity in self-care. The enrollee can continue with an 
effective home exercise 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 occupational therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 12 additional occupational therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computerized corneal topography (92025) provided on 
November 16, 2022. 
 
You asked the Plan to pay for the computerized corneal topography. You say that this service was billed as 
necessary. The Plan denied your request. The Plan says charges for or in connection to services or supplies that 
are, as determined by the Plan, considered to be experimental or investigational are excluded from coverage. 
 
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 computerized corneal topography. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient support in the medical literature for performing 
computerized corneal topography in the setting of cataracts.  
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 computerized corneal topography have not been met. Therefore, we decided 
that the Plan does not have to pay for the computerized corneal topography (92025) provided on November 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service September 5, 
2022. 
 
You asked the Plan to pay for procedure code 99053. The Plan denied your request. The Plan says procedure 
code 99053 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service September 5, 2022.
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 need to improve enrollee's strength, to decrease 
fall risk, to improve standing dynamic balance, ambulation with least restrictive device and to improve the 
enrollee's safety awareness. The Plan denied your request. The Plan says you 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
respiratory failure and COPD exacerbation. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. There is not a reasonable expectation that you 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: 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 requesting an expedited reconsideration for 
the denial of an IRF admission. You say you were independent before your hospitalization, and you want to 
return to being independent. The Plan denied your request. The Plan says criteria for admission to the IRF 
setting have 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 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 pay for inpatient hospital services provided on August 22, 2022, to 
August 26, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 provided with principal diagnosis code A41.51, described as 
Sepsis due to Escherichia coli (E. coli). 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 
inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does not support 
the billed code. Our physician reviewer found the provided documentation did not sufficiently describe sepsis 
from Escherichia Coli (A41.51) as the Sepsis 3 criteria were not met. There was no evidence of a dysregulated 
host response to a systemic infection causing organ dysfunction. Bilirubin was 1.4 but reduced with fluids, 
platelets were normal, creatinine was normal, no hypoxia was noted, no significant oliguria, BP was stable, and 
glasgow coma scale (GCS) 15.  
 
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 hospital services provided on August 22, 2022, to August 26, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
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 it is medically necessary for the enrollee. The Plan 
denied your request. The Plan says it is not medically necessary for the enrollee. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for sepsis and pneumonia. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. There is not a reasonable expectation that this 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: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay $40 more for the ultraviolet lens and deluxe lens feature. We decided that 
the Plan does not have to pay more than $40 for the ultraviolet lens and deluxe lens feature.  
 
 
 You asked the Plan to pay for the ultraviolet lens (V2755) and deluxe lens feature (V2702) purchased on 
January 3, 2023. You say that this is for replacement eyeglasses due to cataract surgery. The Plan says that the 
rendered services processed with the corresponding $459.20 coinsurance after the Plan paid $100 towards the 
purchase. 
 
We decided that the Plan has to pay $40 more for the ultraviolet lens and deluxe lens feature.  
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $100 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses once per calendar year. 
 
We looked at the file and the Plan's rules. The provided documentation does not show that the Plan paid the full 
$100 allowance toward your eyewear purchase. Specifically, the case file and additional information submitted 
support that the Plan only paid $60 toward the vision services provided on January 3, 2023. Your Evidence of 
Coverage clearly states that you have a $100 benefit per calendar year for eyewear. Based on this information, 
we decided that the Plan's rules for coverage of the ultraviolet lens and deluxe lens feature have been met. 
Therefore, we decided that the Plan has to pay $40 more for the ultraviolet lens and deluxe lens feature.  
 
We also decided that the Plan does not have to fully pay for the ultraviolet lens and deluxe lens feature. 
 
We looked at the file and the Plan's rules. The submitted records show that the Plan only paid $60 for the 
eyewear purchased on January 3, 2023, and we have decided that the Plan must pay an additional $40 for the 
ultraviolet lens and deluxe lens feature. This would exhaust your $100 eyewear benefit. Based on this 
information, we decided that the Plan's rules for additional coverage of the ultraviolet lens and deluxe lens 
feature have not been met. Therefore, we decided that the Plan does not have to fully pay for the ultraviolet 
lens and deluxe lens feature. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device (22869). 
 
You asked the Plan to pre-approve a Vertiflex device. You say that this is covered by Medicare. You also say 
that the Vertiflex device is less risky and less invasive than the multi-level fusion. The Plan denied your 
request. The Plan says the requested device is 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 Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested device is considered experimental as additional research is needed. 
Therefore, the reviewer found that the requested Vertiflex device 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for intraoral, comprehensive series of 
radiographic images (code D0210), oral hygiene instructions (D1330), take-home drugs (code D9630) 
periodontal scaling and root planning (D4341) and oral/facial photographic images (D0350) provided on 
September 21, 2022, and September 22, 2022. 
 
You asked the Plan to pay an additional amount for intraoral, comprehensive series of radiographic images 
(code D0210), oral hygiene instructions (D1330), take-home drugs (code D9630) periodontal scaling and root 
planning (D4341) and oral/facial photographic images (D0350). You say that you visited a new dentist for a 
simple cleaning, and you believe these services were not needed or were not done. The Plan denied your 
request. The Plan says the claims processed correctly based on the Plan's dental 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 services are not among 
those covered under this benefit or have paid based on the Plans dental benefit. Therefore, we decided that the 
Plan does not have to pay an additional amount for intraoral, comprehensive series of radiographic images 
(code D0210), oral hygiene instructions (D1330), take-home drugs (code D9630) periodontal scaling and root 
planning (D4341) and oral/facial photographic images (D0350) provided on September 21, 2022, and 
September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mastectomy bras (L8000).
You asked the Plan to pre-approve additional mastectomy bras. You say that you need these items. The Plan denied your request. The Plan says that the benefit maximum has been reached for this item. Maximus overturned the Plan's denial because they did not show proof that they have already paid for and covered mastectomy bra for you. The Plan has requested a reopening and provided proof that they have provided coverage for a mastectomy bra.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional mastectomy bras have not been met. Therefore, we decided that the Plan does not have to pre-approve additional mastectomy bras (L8000).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from December 15, 
2020, to January 3, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
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 provided with diagnosis code J15.6. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the enrollee presented with confusion and cough. Imaging showed evidence of pneumonia 
and pleural effusion. The enrollee was treated with antibiotics and thoracentesis. However, the provided 
documentation did not clearly show evidence of a gram-negative organism causing the diagnosed pneumonia 
as there was no reported sputum culture or other culture results to describe this. Therefore, the diagnosis code 
J15.6 is not supported in the records; however, pneumonia is supported.   
 
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 hospital services rendered from December 15, 2020, to January 3, 2021.