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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided from 
August 1, 2019, to August 30, 2019. 
 
You asked the Plan to waive the coinsurance for the radiation therapy. You say that you received the bill very 
late and the charges have not been explained. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 radiation therapy at an outpatient hospital or freestanding radiological facility. 
 
 Service Allowed Amount 20% Coinsurance 
Radiation Therapy  August 1, 2019 $524.56 $104.91 
Radiation Physics Consult  August 2, 2019 $124.89 $24.98 
Radiation Therapy  August 2, 2019 $524.56 $104.91 
Radiation Therapy  August 5, 2019 $524.56 $104.91 
Radiation Therapy  August 6, 2019 $524.56 $104.91 
Radiation Therapy  August 7, 2019 $524.56 $104.91 
Radiation Therapy  August 8, 2019 $524.56 $104.91 
Radiation Physics Consult  August 9, 2019 $124.89 $24.98 
Radiation Therapy  August 9, 2019 $524.56 $104.91 
Radiation Therapy  August 12, 2019 $524.56 $104.91 
Radiation Therapy  August 13, 2019 $524.56 $104.91 
Radiation Therapy  August 14, 2019 $524.56 $104.91 
Radiation Therapy  August 15, 2019 $524.56 $104.91 
Radiation Physics Consult  August 16, 2019 $124.89 $24.98 
Radiation Therapy  August 16, 2019 $524.56 $104.91 
Radiation Therapy  August 19, 2019 $524.56 $104.91 
Radiation Therapy  August 20, 2019 $524.56 $104.91 
Radiation Therapy  August 21, 2019 $524.56 $104.91 
Radiation Therapy  August 22, 2019 $524.56 $104.91 
Radiation Therapy  August 23, 2019 $524.56 $104.91 
Radiation Physics Consult  August 26, 2019 $124.89 $24.98 
Radiation Therapy  August 26, 2019 $524.56 $104.91 
Radiation Therapy Dose Plan  August 27, 2019 $999.10 $199.82 
Radiation Therapy  August 27, 2019 $524.56 $104.91 
Radiation Therapy  August 28, 2019 $524.56 $95.92* 
Radiation Therapy  August 29, 2019 $524.56 $0.00 
Radiation Therapy  August 30, 2019 $524.56 $0.00 
Total:  $2,388.95 
 
* Note  Maximum out-of-pocket expenses for the year was met on this date of service. 
 
You have been asked to pay a total of $2,388.95, which is 20% of the allowed amount for the radiation therapy. 
The radiation therapy falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
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 radiation therapy services 
provided from August 1, 2019, to August 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 10, 2021, 
through December 1, 2021. 
 
You asked the Plan to pay for the home health services. You say that the RAP timely filing date should not be 
enforced because this is done to update the Common Working File which is not required for Medicare 
Advantage enrollees. The Plan denied your request. The Plan says payment was correctly denied as the RAP 
was not timely filed. 
 
The Plan must follow Medicare rules. Medicare rules say that home health payments are reduced by 1/30th for 
every day beyond the 5-day timely filing date that a RAP is not received.   
 
We looked at the file and Medicare rules. The RAP for this episode of care was not received until more than 30 
days after the From date on the claim. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for the 
home health services provided from November 10, 2021, through December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on 
October 18, 2021, and October 25, 2021. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 a hospital outpatient clinic visit provided on October 18, 2021, 
and October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device has been determined to be of uncertain value in the most recent guidelines. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor device placed 
in the pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with 
CHF. The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of 
CardioMEMS.  Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time 
the CardioMEMS system would not be considered medically appropriate and necessary in this patients 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on January 
4, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you were informed that all 
COVID-19 related costs were waived. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 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 $45 
copayment for services obtained from a specialist.  
 
The file does not indicate that cost share waivers for COVID-19 were in effect on the date of service. 
Therefore, you have been asked to pay a $45 copayment for the specialist visit. The specialist visit falls within 
the Physician/Practitioner Services, Including Doctor's Office Visits 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 office visit provided on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 22, 2021. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you were under the impression 
that this was your annual visit. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $15 
copayment for specialist visits.  
 
The records show that you were seen by a specialist physician for groin pain. Therefore, you have been asked 
to pay a $15 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits 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 office visit provided on December 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a computed tomography (CT) scan of the 
abdomen and pelvis provided on March 19, 2022. 
 
You asked the Plan to waive the coinsurance for the CT scan. You say that you cannot afford the bill. The Plan 
denied your request. The Plan says the correct coinsurance was applied. 
 
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 up to $75 per day for diagnostic radiology services, including CT scans.  
 
You have been asked to pay $70.11, which is 20% of the allowed amount for the CT scan ($350.55 allowed 
amount x 20% coinsurance = $70.11). The CT scan falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies 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 a 
computed tomography (CT) scan of the abdomen and pelvis provided on March 19, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after July 28, 
2022. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is not able to go home. You also say 
that it is recommended that she has 24 hour care. The Plan denied your request. The Plan says that their 
medical director has determined that this request is not medically necessary or reasonable. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before July 28, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continued skilled nursing facility (SNF) services after July 28, 2022.  
 
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 neurology visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the neurology visit. You say that the out-of-network consult is medically 
necessary. The Plan denied your request. The Plan says there are network providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
neurology visit 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 pay for the subsequent inpatient physician services provided on 
January 11, 2022, billed with code 99233. 
 
You asked the Plan to pay for the inpatient physician services. You say that this was medically necessary care. 
The Plan denied your request. The Plan says the hospital stay was only approved for dates in December. Since 
there was no approval for this date of service, the denial was correct. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also require that the code billed be appropriate for the services rendered. 
 
The CPT Manual definition of code 99233 is subsequent hospital care, per day, for the evaluation and 
management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A 
detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has 
developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
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 physician services. Our 
reviewer says that the services rendered are not considered medically reasonable and necessary based on the 
code billed. Our physician reviewer found the enrollee was a female who was admitted on December 25, 2021. 
She was treated for urinary tract infection, hypertensive urgency, acute kidney injury, and non-ST elevation 
myocardial infarction. She required evaluations by Cardiology and Nephrology. On 1/11/2022, the 
documentation did not meet the criteria for coverage for CPT code 99233. There was no evidence for the 
patient being unstable with significant new complications or problems. The review has determined that the 
subsequent hospital care provided (CPT 99233) on January 11, 2022, was 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 the inpatient physician services have not been met. Therefore, we decided that 
the Plan does not have to pay for the subsequent inpatient physician services provided on January 11, 2022, 
billed with code 99233.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cooling vest (E1399). 
 
You asked the Plan to pre-approve the cooling vest. You say that the cooling vest is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a cooling vest (E1399).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for transfer from an IRF to a SNF.
You asked the Plan to provide coverage for this transfer. You say that at the time of the appeal, this transfer
was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer
were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did
not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF admission.
The Maximus Physician Reviewer determined that you had daily skilled therapy needs. The Plan has stated that
it disagrees with our consultant's determination. The Plan notes that Medicare states "the goal of an IRF stay is
to enable a patient's safe return to the home or community-based environment upon discharge, the patient's
treatment goals and achievements during an IRF admission are expected to reflect significant and timely
progress toward this end result." The Plan argues that you could have remained in the IRF in order to achieve
maximal functional benefit from an intensive therapy program to enable safe return to the home or community based
environment in a timely manner.
The Plan is correct in this case. The request did not meet Medicare coverage guidelines, as you were receiving
adequate and necessary care in the IRF. The documentation does not support that transfer to a SNF for inpatient
skilled rehab services was medically reasonable and necessary in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this transfer have not been met. Therefore, we decided that the Plan does not
have to pre-approve transfer from an inpatient rehabilitation facility (IRF) to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from December 17, 
2021, to December 20, 2021. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the skilled nursing services provided from 
December 17, 2021, to December 20, 2021. Our reviewer says that the enrollee did not meet the Medicare 
criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that 
required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not 
have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from December 17, 2021, to December 20, 2021.