Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that at the time of the appeal, SNF admission was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services. The Maximus Physician Reviewer determined that the clinical documentation supported that the enrollee required skilled nursing care for continued management of blood glucose and blood pressure. The Plan requested a reopen and argued the medical records do not clearly establish that there was likely potential for serious complications without skilled management. The Plan is correct in this case. The documentation does not support that you required skilled nursing and/or skilled therapy services daily on an inpatient basis, in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have waive the copayment for laboratory services provided on August 9, 
2022.   
 
You asked the Plan waive the copayment for laboratory services. You say that your provider recommended that 
you get your blood work done ahead of your scheduled annual physical so you could discuss several possible 
issues related to your treatment plan. You also say that it is your understanding that laboratory work done in 
conjunction with your annual physical is done at no charge and no copayment. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment per day for laboratory tests that are not FIT tests.  
 
 
 
 You have been asked to $10 for laboratory services. This item/service falls within the laboratory tests that are 
not FIT tests 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 waive the copayment for laboratory services provided 
on August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cochlear implantation. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request is not medically necessary because the records do not show open-set 
sentence testing of less than or equal to 40%. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the the record indicates that the enrollee has bilateral sensorineural hearing loss. The record 
does not indicate that the enrollee has limited benefit from amplification as defined as test scores of less than or 
equal to 40% correct in the best-aided listening condition on tape-recorded tests of open-set sentence 
cognition. The elements of the coverage criteria are not satisfied. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cochlear implantation.
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 admission to IRF care is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. Skilled therapies at home or at a skilled nursing facility may be approved upon request. 
 
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 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 pre-approve acute IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve oncology services with an out-of-network provider. You say that you want 
the Plan to approve the services. The Plan denied your request. The Plan says you have in-network oncologists 
available in your area and therefore, this request will not be covered. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
oncology services to be provided by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nutritional counseling (S9470). 
 
You asked the Plan to pre-approve nutritional counseling. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request service is not a covered 
benefit in the enrollee's clinical situation. 
 
The Plan must follow Medicare rules. Medicare rules say that MNT is covered for a diagnosis of renal disease 
or diabetes.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of nutritional counseling have not been met. Specifically, the available medical records do not support 
a diagnosis of renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve 
nutritional counseling (S9470).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 injection for your knee. 
 
You asked the Plan to pre-approve injection for your knee. You say that you disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says the requested drug will be supplied by 
a pharmacy and therefore, not covered under your medical benefit. Your medications must be supplied by your 
medical provider or medical facility. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy. Since the 
medication does not represent an expense to the physician and will not be included in the physician's bill, it is 
not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 
injection for your knee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 27, 
2022, and March 29, 2022 
 
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford to pay this. 
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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services. Your contract with the Plan also clearly says that cost sharing applies for 
each one-way trip. 
 
You have been asked to pay $1000 for ambulance services ($250 x 4 one-way trips = $1000). These 
items/services fall within the ambulance 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 ambulance services provided on March 27, 2022, and March 29, 2022
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to lower the coinsurance for dexamethasone injection. We decided that the Plan 
does not have to waive the cost sharing for cataract surgery.  
 
You asked the Plan to waive the cost sharing for cataract surgery and dexamethasone injection provided on 
May 24, 2022. You say that you do not feel the cost share is a correct amount. The Plan says that this cost 
sharing was charged correctly. 
  We decided that the Plan has to lower the coinsurance for dexamethasone injection.  
 
The rules say a health 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
The Plan says you must pay $116.33 for a dexamethasone injection, which is 20.16% of the allowed amount of 
$576.98. Based on the Plan contract, however, you cannot be asked to pay more than 20% for dexamethasone 
injections, which in this case would be $115.40. It appears the Plan made a calculation error for the approved 
amount. Therefore, we decided that the Plan has to lower the copayment for dexamethasone injection.  
 
We also decided that the Plan does not have to waive cost sharing for cataract surgery and 
dexamethasone injection. 
 
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 $200 
copayment per visit for Medicare-covered outpatient surgery or procedure at an ambulatory surgical center 
(ASC) and 20% coinsurance for Medicare Part B prescription drugs. Therefore, we decided that the Plan does 
not have to waive the cost sharing for cataract surgery and dexamethasone injection. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan (78816). 
 
You asked the Plan to pre-approve a PET/CT scan. You say that you think the PET/CT scan is clinically 
indicated for the enrollee. The Plan denied your request. The Plan says there is no confirmed diagnosis of 
cancer, and the documentation does not support symptoms or signs of a neoplastic process. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 a PET/CT scan. Our physician reviewer 
found a review of the chart notes and records fails to show any indication for a PET/CT. However, in the letter 
of appeal, the attending orthopedist said the enrollee had a magnetic resonance imaging (MRI) of the lumbar 
spine, a 7 mm zone of hypointensity on T1 and T2 was present, and since the enrollee had a lung mass removed 
in the past, metastatic disease would be considered possible, and a PET/CT should be done for correlation. Our 
reviewer found that there is no enclosed MRI report, no notes describing any lung mass, benign or malignant or 
any other details concerning any tumor of any kind in the past. Our physician reviewer also found that the 
medical necessity of the requested PET/CT is not demonstrated in the records provided. 
 
 
 
 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 PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) scan (78816).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100). 
 
You asked the Plan to pre-approve additional non-emergency transportation (A0100). You say that the member 
must see his therapist once a week. You also say the location for the provider is not in walking distance. The 
Plan denied your request. The Plan says your request exceeds the benefit limit for the transportation program. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
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 would benefit from inpatient rehabilitation 
services due to your medical complexity. The Plan denied your request. The Plan says your needs can be met at 
a lower level of care such as skilled nursing facility (SNF), home health 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 there are no complex nursing or rehabilitation needs. While you have 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 pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), heart, without contrast 
material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve a CT of the heart without contrast material, with quantitative evaluation of 
coronary calcium. You say that the service is medically necessary. The Plan denied your request. The Plan says 
Medicare does not cover the requested study for screening purposes. 
 
The Plan follows Medicare rules. Medicare rules say that CT scans are covered only when they are medically 
necessary. Medicare rules say a CT of the heart without contrast material, with quantitative evaluation of 
coronary calcium is never covered for screening. 
 
   
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 CT of the heart without contrast 
material, with quantitative evaluation of coronary calcium. Our reviewer says that you do not meet coverage 
criteria for the requested service. Our physician reviewer found you have hyperlipidemia but no symptoms to 
suggest coronary artery disease. Medicare does not cover CT coronary calcium scoring for an asymptomatic 
patient unless there is a calculated 10-year risk of coronary disease between 9-19%. There is no such 
calculation in the records. Thus, the requested CT coronary calcium scoring test is not covered. 
 
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 CT of the heart without contrast material, with quantitative evaluation of 
coronary calcium have not been met. Therefore, we decided that the Plan does not have to pre-approve 
computed tomography (CT), heart, without contrast material, with quantitative evaluation of coronary calcium 
(75571).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81479 provided on June 24, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the documentation shows 
that the specimen was collected on June 13, 2022. This does not match the billed date of service. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81479 provided on 
June 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to an LTACH care. 
 
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 receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the modified barium swallow (92611), radiologic examination, spine, cervical; 2 or 3 views (72040) and radiologic examination, gastrointestinal tract, upper (74240) provided to the enrollee on October 20, 2021.
You asked the Plan to pay for these services. You say that the services were medically necessary. The Plan denied your request. The Plan says that these services are not covered at this place of service.
The Plan must follow Medicare rules. Medicare rules say that a modified barium swallow is only covered when performed in certain locations. 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 radiologic examination, spine, cervical; 2 or 3 views (72040) and radiologic examination, gastrointestinal tract, upper (74240). Our reviewer says that the radiologic examination, spine, cervical; 2 or 3 views (72040) and radiologic examination, gastrointestinal tract, upper (74240) are not considered medically reasonable and necessary in this case. We looked at the physician's review, the file and Medicare rules. The file indicates the enrollee did not receive the modified barium swallow in a qualifying place of service. 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 pay for the modified barium swallow (92611), radiologic examination, spine, cervical; 2 or 3 views (72040) and radiologic examination, gastrointestinal tract, upper (74240) provided to the enrollee on October 20, 2021.