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

 
We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from 
January 6, 2022, forward. 
 
You asked the Plan to pre-approve the continuation of inpatient mental health care. You say that inpatient 
mental health care continues to be medically necessary. The Plan denied your request. The Plan says the 
requested inpatient mental health care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 continuation of inpatient mental 
health care. Our reviewer says that the requested inpatient mental health care is not medically reasonable and 
necessary. Our physician reviewer found based upon review of the records provided it was not expected this 
enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any 
dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. This patient 
was compliant and cooperative with treatment. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates 
in question as he did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. The 
health plans denial of continued inpatient psychiatric services appears appropriate. 
 
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 continuation of inpatient mental health care have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from 
January 6, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural block with an out-of-network provider. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 an 
epidural block with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share amount for a sacroiliac injection provided on October 18, 2021.
You asked the Plan to reduce the cost share amount for a sacroiliac injection. You say that you got a shot in your back that only took five minutes. You also say that you were expecting to pay 20% coinsurance. 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 $550 copayment for in-network outpatient ambulatory surgery. The injection you received is considered a surgical service. You have been asked to pay a $550 copayment for a sacroiliac injection. A sacroiliac injection falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 reduce the cost share amount for a sacroiliac injection provided on October 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was diagnosed with Alzheimer's disease by positron emission tomography (PET) scan in 2017. It is noted that her memory has continued to deteriorate. The clinical documentation and imaging studies document a mixed etiology for the enrollee's symptoms, with evidence of both Alzheimer's disease and vascular cognitive impairment. It has not been shown that Aduhelm is at least as beneficial as existing and appropriate and available medically appropriate alternatives. It is not clearly established that Aduhelm is reasonably expected to be safe and effective for this enrollee.
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 Aduhelm.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0482) provided on January 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says prior authorization was not obtained by the provider.
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 the drug testing services (G0482) provided on January 5, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found based on the documentation provided the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
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 a skilled nursing facility will not provide the adequate physician, nursing and therapy coverage and care for your current health status. In addition, you are not a candidate at the time for acute rehabilitation and have too many complications at this time for a lower level of care. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage.
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 you appear to be currently unstable and still require short-term acute care services that can be safely administered at the current facility until you are stable for a lower level of care. You do not require services at the LTACH that are not already available at the current facility. 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. 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 an SCS 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 failed back surgery 
syndrome with constant pain following extensive surgery for spinal stenosis from L2 to L5/S1. He is currently 
on Tramadol, Celebrex, Cymbalta and Flexeril. He has completed physical therapy and continues with aquatic 
therapy. He has had epidural steroid injections and has been cleared by a psychologist for the trial. He has 
failed conservative therapy and is a candidate for the SCS trial. The services are 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 a spinal cord stimulator (SCS).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide visits, 3 times per day. 
 
You asked the Plan to pre-approve home health services. You say that you need these services. You also say 
that you do not qualify for Medicaid. The Plan denied your request. The Plan says the services are not 
necessary. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home 
health aide visits, 3 times per day.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient physical therapy (PT) 
services (97110, 97140, G0283, and 97010) provided on February 16, 2021. 
 
You asked the Plan to waive the copayment for the outpatient PT services. You say that you feel you should 
not be liable for the charge because the provider left the tens unit on too high and burned you. You also say that 
you were left with a scar. The Plan denied your request. The Plan says the claim has processed correctly 
according to the contract with the Plan. 
 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 $40 
copay for each Medicare-covered visit, including physical therapy, speech and language pathology, and 
occupational therapy for Outpatient rehabilitation services.  
 
You have been asked to pay a $40 copay for each Medicare-covered visit, including physical therapy, speech 
and language pathology, and occupational therapy for the outpatient PT services. The outpatient PT services 
falls within the Outpatient rehabilitation services benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the outpatient physical therapy (PT) services (97110, 97140, G0283, and 97010) provided on 
February 16, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total electric hospital bed, with any type side rails, 
with mattress (E0265). 
 
You asked the Plan to pre-approve the hospital bed. You say that the enrollee had a stroke and is not able to 
stand. You are the main caregiver and the up and down function is needed by the enrollee. The Plan denied 
your request. The Plan says a total electric hospital bed is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric 
hospital bed, with any type side rails, with mattress (E0265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ophthalmological services (92014), frames (V2020), 
and bifocal (V2200), provided on October 5, 2021, through October 8, 2021. You asked the Plan to pre-approve the ophthalmological services, frames, and bifocal. You say that the services 
were medically necessary. The Plan denied your request. The Plan says you obtained these services out-of-
network. 
 
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 these services when services are only covered when received by a participating 
provider. 
 
We looked at the file and the Plan's rules. you received these services out-of-network with no prior 
authorization. Based on this information, we decided that the Plan's rules for coverage of the ophthalmological 
services, frames, and bifocal have not been met. Therefore, we decided that the Plan does not have to pre-
approve the ophthalmological services (92014), frames (V2020), and bifocal (V2200), provided on October 5, 
2021, through October 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the muscle-skin graft (15734) and hernia repair (49560) 
provided on September 23, 2021. 
 
You asked the Plan to pay for the muscle-skin graft (15734) and hernia repair (49560). You say that the 
medical records support the billing. You say that the records should be reviewed and the claim reconsidered for 
payment. The Plan denied your request. The Plan says the services are not supported by the medical records. 
 
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 15734 is muscle, myocutaneous, or fasciocutaneous flap; 
trunk. The CPT Code Manual definition of code 49560 is repair initial incisional or ventral hernia; reducible. 
 
  We asked our coder 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 muscle-skin graft (15734) and hernia repair (49560). Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found that the operative report does not describe a myocutaneous or fasciocutaneous flap, as there is 
not documentation to support a donor site. Therefore, procedure code 15734 cannot be verified. Our reviewer 
also says that a hernia repair would not be reported separately when another procedure is being performed 
through same site. Therefore, this procedure would not be covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the muscle-skin graft (15734) and hernia repair (49560) have not been met. 
Therefore, we decided that the Plan does not have to pay for the muscle-skin graft (15734) and hernia repair 
(49560) provided on September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 18, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee meets the requirements of the 
national coverage determination (NCD) and the services provided were reasonable and necessary. The Plan 
denied your request. The Plan says the enrollee's primary care physician did not refer the enrollee to an out-of-
network provider for this service and the service provided was not urgent or emergent. 
 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 laboratory services provided on June 18, 2021, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is clinically not stable because she continues to require high flow oxygen and acute care services. The enrollee continues to receive acute care services, and these have not been denied. The enrollee does not require services that she is not currently receiving but that would be available at the LTACH facility.
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 pre-approve implantable/insertable device, not otherwise classified 
(C1889). 
 
You asked the Plan to pre-approve the implantable/insertable device. You say that the medical records 
provided will show proof of medical necessity. The Plan denied your request. The Plan says this service is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the implantable/insertable device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implantable/insertable device, not otherwise classified (C1889).