Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carotid endarterectomy, angiography and hospital 
inpatient admission for the enrollee to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is not a network deficiency. 
 
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 
carotid endarterectomy, angiography and hospital inpatient admission for the enrollee 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 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Fasenra pen. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Fasenra pen.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein, 
extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency, first vein treated 
(36475). 
 
You asked the Plan to pre-approve endovenous radiofrequency. You say that your foot is swollen, and you are 
having problems walking from the blood that is not going back up your leg. The Plan denied your request. The 
Plan says the records do not support that all the criteria has been met and the does not meet medical necessity 
criteria. 
 
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 endovenous radiofrequency. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in summary, all criteria have been met other than documentation of CEAP 
and VCSS scores. Recommend resubmitting with the required scores, otherwise the procedure appears to be 
reasonable and medically necessary, and it partially meets the LCD criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous radiofrequency have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endovenous ablation therapy of incompetent vein, extremity, inclusive of all 
imaging guidance and monitoring, percutaneous, radiofrequency, first vein treated (36475).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve inpatient psychiatric services. You say that it is in your best interest to stay 
inpatient to avoid risk of rehospitalization. You say that the requested inpatient treatment is medically 
necessary. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The 
Plan says that the enrollee's needed care can be provided at a less restrictive level. 
 
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 inpatient psychiatric services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was 
admitted to the acute inpatient psychiatric hospitalization on June 8, 2022, with Schizoaffective Disorder, 
Unspecified Type. Based upon review the records provided it was not expected this enrollee would improve in 
a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation, auditory 
or visual hallucinations. The patient was compliant with treatment while not showing any acute threats to 
safety. 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 she did not have 
dangerousness to self or others and was compliant with her treatment. It did not appear that the services were 
reasonably expected to improve the patients condition or for the purpose of diagnosis beyond the date in 
question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids, digital, binaural, behind the ear (V5261) 
provided December 23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you were not aware that you had to go through a 
specific hearing vendor. The Plan denied your request. The Plan says the hearing aids are not covered because 
they were provided OON. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only purchased from a provider in the Plans hearing aid network. 
 
We looked at the file and the Plan's rules. In this case the hearing aids were purchased OON. Based on this 
information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we 
decided that the Plan does not have to pay for the hearing aids, digital, binaural, behind the ear (V5261) 
provided December 23, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (85060) provided on February 9, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not payable 
for this place of service. 
 
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 payment for CPT code 85060 is not supported in the medical record. Specifically, the code 85060 
is assigned a PC/TC indicator of 8. This means that payment for this code cannot be made for hospital 
outpatients or non-hospital patients. The claim was billed with an outpatient place of service. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. 
 
 
 
 
 
  
 
 Therefore, we decided that the Plan does not have to pay for the services (85060) provided on February 9, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift mechanism (Infinite Position Lift Chair) and 
sales tax for the item received on November 10, 2021 to December 10, 2021. 
 
You asked the Plan to pay for the seat lift mechanism and sales tax. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says you did not meet criteria for the item 
received. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 pay for the seat lift mechanism and sales tax. Our 
reviewer says that the documentation does not support that the item provided was medically reasonable or 
necessary. Our physician reviewer found you had a total hip replacement procedure on November 1, 2021.  The documentation shows that the chair was ordered as part if your post-operative care. The provided records do 
not document that the enrollee is completely incapable of standing from a chair in the home. The 
documentation supports that you had the ability to ambulate. This means you did not meet criteria for the item 
received. 
 
Sales tax is never a covered charge. We looked at this physician's review, the file, and Medicare rules for the 
seat lift mechanism. Based on this information, we decided that Medicare rules for coverage of the seat lift 
mechanism and sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the 
seat lift mechanism (Infinite Position Lift Chair) and sales tax for the item received on November 10, 2021 to 
December 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF services would result in significant 
improvement in the enrollee's functional capabilities. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for SNF care and the services the enrollee requires is custodial care as the enrollee still 
needs help with dressing, bathing, and getting in and out of bed. 
 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 pre-approve SNF services. Our physician reviewer 
found that the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, 
and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services
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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing rendered on December 2, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 
81455 are denied as not medically necessary. 
 
We looked at the file and Medicare rules. The services are billed under code 81455. 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 genetic testing rendered on December 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (82542) provided on June 16, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not separately 
payable. 
 
Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for 
services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the 
beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to 
this service would have been included under the facility claim. Therefore, we decided that the Plan does not 
have to pay for the lab services (82542) provided on June 16, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on November 8, 
2021. 
 
You asked the Plan to pay for the F1CDx testing. You say that this is a Food and Drug Administration (FDA) 
approved test that was ordered by the treating physician. The Plan denied your request. The Plan says that the 
submitted records do not indicate that the enrollee is seeking further treatment which is one of the criteria from 
the National Coverage Determination 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The Plan failed to indicate the network status of the ordering physician in this case. However, Maximus found 
that this provider is listed as in-network with this Plan on the plan website. The file does not show that the plan 
provided notice that the F1CDx testing would not be covered. Under Medicare rules, this means the F1CDx 
testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
FoundationOne CDx (F1CDx) testing provided on November 8, 2021.  
 
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: 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
20, 2021. 
 
You asked the Plan to pay for home health services. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. The claim does not show that the applicable 
G and Q codes were billed as required. Based on this information, we decided that Medicare rules for 
completing the claim for home health services have not been met. Therefore, we decided that the Plan does not 
have to pay for the home health services provided to the enrollee from April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses received on December 2, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that you should get a reimbursement of $200. The Plan 
denied your request. The Plan says the claim has been processed correctly per your plan benefits. 
 
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 anything 
over $200 for vision services.  
 
Review of the file shows that the total retail amount for the eyeglasses received were $698.95. The Plan paid 
$200 toward your eyeglasses received on December 2, 2021. You have been asked to pay anything over $200 
for the eyeglasses. The eyeglasses fall within the vision 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 pay for the eyeglasses received on December 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiogram (ECG) interpretation and report (93010, 
93010-76) provided on August 31, 2021. 
 
You asked the Plan to pay for ECG interpretation and report. You say that these services were billed 
appropriately. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 92960 and 93010. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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, we have confirmed that code 93010 
is a column II code to column I code 92960. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for electrocardiogram (ECG) interpretation and report (93010, 
93010-76) provided on August 31, 2021.