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

 
We decided that the Plan does not have to pay for the laboratory services provided on October 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed. The 
Plan denied your request. The Plan says the claim has been denied correctly as screening tests are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services provided on 
October 11, 2021, have been met. In this case, medical records have not been provided by the ordering 
physician indicating the medical necessity of the requested procedure. Therefore, we decided that the Plan does 
not have to pay for the laboratory services provided on October 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on June 9, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that another claim for a different date of service 
for the same procedure was partially paid. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan, and authorization was not obtained prior to the services being rendered. The Plan also 
says that regarding the appellant's statement that the Plan paid for similar services rendered on a different date 
of service, February 18,2021, they reviewed their records and determined that the date of service, February 18, 
2021, was paid due to an administrative error. 
 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 therapeutic exercises (97110) provided on June 9, 
2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on 
December 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the patient is in a nursing facility 
and should not have needed a referral/authorization. The Plan denied your request. The Plan says this provider 
is not a network provider with the Plan, and they have 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 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 a domiciliary or rest home visit (99336) provided 
on December 30, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical fusion surgery. 
 
You asked the Plan to pre-approve the requested services. You say that  The Plan denied your request. The Plan 
says there is no documentation of significant foraminal or central canal stenosis. 
 
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 requested services. Our physician 
reviewer found that the imaging studies provided do not show evidence of severe spinal stenosis. Therefore, the 
requested services are not medically reasonable or necessary at this time. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cervical fusion surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-sterile gloves (A4927) surgical mask, per 20 
(A4928) sterile gloves (A4930) urinary catheter anchoring device, adhesive skin attachment (A4333) adhesive 
remover or solvent (A4455) percutaneous catheter/tube anchoring device, adhesive skin attachment (A5200) 
gauze, non-impregnated, sterile (A6402) transparent film, sterile (A6258) and Betadine or iodine swabs/wipes 
(A4247). 
 
You asked the Plan to pre-approve the left ventricular assist device supplies. You say that you are attaching 
supporting documents and a summary of service. The Plan denied your request. The Plan says this kit is a 
convenience item and not medically necessary as the supplies re readily available for standardized assembly 
and use. The kit does not provide outcomes which cannot be achieved with usual care. 
 
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 non-sterile gloves (A4927) surgical mask, per 20 (A4928) 
sterile gloves (A4930) urinary catheter anchoring device, adhesive skin attachment (A4333) adhesive remover 
or solvent (A4455) percutaneous catheter/tube anchoring device, adhesive skin attachment (A5200) gauze, 
non-impregnated, sterile (A6402) transparent film, sterile (A6258) and Betadine or iodine swabs/wipes 
(A4247).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assembly and operation of pump (99190 and 99191), 
autologous blood or component (86891) and red blood cells (P9022) provided on June 8, 2021. 
 
  You asked the Plan to pay for assembly and operation of pump (99190 and 99191), autologous blood or 
component (86891) and red blood cells (P9022). You say that the patient did not have a choice of Perfusion 
providers because our service was arranged directly with the surgeon and facility. You say that the claim 
should be reprocessed according to the patients in- network level benefits since the services are considered 
medically necessary. The Plan denied your request. The Plan says CPT codes 99190, 99191, 86891 and P9022 
are included in payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that all items and non-physician 
services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under 
arrangements. 
 
We find that CPT codes 99190, 99191, 86891 and P9022 are not supported in the medical record. Specifically, 
services furnished to inpatients must be furnished by the hospital or billed through the hospital. Based on this 
information, we decided that Medicare rules for coverage of assembly and operation of pump (99190 and 
99191), autologous blood or component (86891) and red blood cells (P9022) have not been met. Therefore, we 
decided that the Plan does not have to pay for assembly and operation of pump (99190 and 99191), autologous 
blood or component (86891) and red blood cells (P9022) provided on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 24, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim has not been billed with an 
appropriate place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on March 24, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency department visit (99283) 
rendered on August 16, 2021. 
 
You asked the Plan to waive the copayment for an emergency department visit. You say that the physician 
walked into the room and informed you he could not help you go off of a drug that he did not prescribe. The 
Plan denied your request. The Plan says you were 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for an emergency department visit. Emergency department visits 
fall within the emergency care 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 an 
emergency department visit (99283) rendered on August 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. 
 
Your complaint about the potentially poor customer service from both your providers office staff, and the 
emergency room staff is not a valid appeal for medical coverage. This part of your complaint is a grievance that 
must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 service is medically necessary. The Plan denied 
your request. The Plan says the service 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 your medical conditions are stable and there are no complex nursing or 
rehabilitation needs. While you may have a need for physical and/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. Specifically, medically necessary services can be 
obtained in a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we 
decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and 
services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you need additional SNF days. The Plan 
denied your request. The Plan says SNF care is no longer needed as of April 13, 2022. 
 
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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you have no identifiable skilled 
nursing or skilled therapy needs at this time, so you do not require care 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment purchased from a retail pharmacy 
on October 16, 2021. 
 
You asked the Plan to pay for this equipment. You say that the Plan should pay for the transport chair and other 
items. The Plan denied your request. The Plan says you did not have prior authorization for this equipment and 
this provider is not a Medicare eligible provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items provided by a physician or vendor who is not eligible to accept Medicare payment. The Plan contract 
says that durable medical equipment requires prior authorization. You purchased this equipment from a retail 
pharmacy. You did not follow the Plan contract rules when you purchased this equipment. Therefore, we 
decided that the Plan does not have to pay for durable medical equipment purchased on October 16, 2021.
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 enrollee's needs are too complex for 
a skilled nursing facility level of care. The Plan denied your request. The Plan says there are no issues for 
which an LTACH may offer a therapeutic advantage. 
 
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 physician 
reviewer found that the enrollee presented to the acute care hospital with pleural effusions and respiratory 
failure. She continues to have high chest tube output. She is not a candidate for surgical intervention. She is 
receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that 
she requires that are not available at the health care setting being offered by the health plan. Therefore, the 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the 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 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: 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 the SNF services. You say that that the enrollee needs continued ongoing 
therapy due to her diagnoses of Acute Encephalopathy with Dellrium; possible early Dementia; possible auto 
immune Throiditis; Hyponatremia; and recently diagnosed L4 Compression Fracture. You say her impairments 
include functionality below baseline; significant functional impairments such as unable to care for self and poor 
safety awareness; increased fall risk; unable to provide a level of care on return home as a care giver; and low 
cognition score below baseline. The Plan denied your request. The Plan says a SNF admission is not medically 
necessary. 
 
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 the SNF services. Our reviewer says 
that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing 
perspective, the enrollee received oral medications. The enrollee had stable vital signs. Her lungs were clear.    
Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT).  
The enrollee was at a supervision to independent level for functional mobility including gait to 200 feet. The 
enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service 
needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or 
therapy services on a daily basis. As a practical matter, this enrollee does not meet severity of illness or 
intensity of service criteria for 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech/hearing therapy (92507) provided on February 27, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for speech/hearing therapy. You say that that another claim for a different date of 
service for the same procedure and the same rendering provider was partially paid. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to 
the services being rendered. The Plan also says that the referring provider was out-of-network with the Plan, 
and the services rendered were not Plan directed care. 
 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 speech/hearing therapy (92507) provided on 
February 27, 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 inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says the enrollee 
does not have any acute issues requiring hospitalization. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 services. Our physician 
reviewer found that the enrollee presented to the emergency room with adult failure to thrive. The records 
indicate she had worsening dementia with behavior changes. She had slight worsening of her kidney function 
which improved rapidly with intravenous fluids. The review has determined that the record did not show her 
necessary hospital care would span two midnights. 
 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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient hospital services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
September 22, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that there should be no 
copayment for the ambulance rides since you were advised there would be no charge. The Plan denied your 
request. The Plan says the proper copayment 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for each Medicare-covered ground ambulance transport (one-way).  
 
  The enrollee has been asked to pay a $250 copayment for the ambulance transportation. The ambulance 
transportation falls within the Ambulance services benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for ambulance transportation provided on September 22, 2021.