Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the inpatient 
rehabilitation facility level of care 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 enrollee has a past medical history of asthma, stroke with hemiparesis, 
hypertension, and hyperlipidemia and is living in the community with weakness despite home health services. 
Medical problems are stable.  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99251 billed for date of service  
December 7, 2021. 
 
You asked the Plan to pay for procedure code 99251. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99251 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99251 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 99251 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99251 billed for date of service December 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for basic imaging service provided on June 02, 
2022. 
 
You asked the Plan to waive the copayment for basic imaging service. You say that you are requesting the $20 
copayment to be refunded as the x-ray was performed at your providers office during your post-operation visit. 
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 $20 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $20 copayment for basic imaging service. This item/service falls within the 
outpatient diagnostic test 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 basic 
imaging service provided on June 02, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation over 60 miles one-way. 
 
You asked the Plan to pre-approve routine transportation. You say that you disagree with the denial and would 
like the Plan to reconsider. The Plan denied your request. The Plan says the requested service exceeds the 
benefit limit of 60 miles one-way. 
 
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 routine transportation when 100 one-way trips per calendar year (limited to ground 
transportation only). Each one-way trip must not exceed 60 miles based on the most efficient route. We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine transportation over 60 miles one-way.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Retacrit or Epogen. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Aranesp. Our physician reviewer found 
that the enrollee has anemia due to chronic kidney disease. The Plan requires a trial of Retacrit or Epogen 
before they will approve the requested drug. In this case, the enrollee has not tried and failed the required 
drugs. There is no documentation provided indicating that the Plans required drugs would likely be less 
effective or likely have adverse effects for 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response services provided to the enrollee on October 4, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan states this claim was submitted with an inappropriate modifier. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria.
The Plan says the enrollee received Emergency Triage, Treat, and Transport (ET3) Telehealth Intervention Services which is why the modifier of "W" was used.
However, review of the Emergency Triage, Treat, and Transport (ET3) Model, determined that the only health plans this model is valid for are Medicare Fee for Service (FFS) enrollees. This enrollee is enrolled in a Preferred Provider Organization (PPO) plan. The Plan states the claim denied because the service was billed with an inappropriate modifier. The Plan states this service was billed with a Modifier "RW" which is not an appropriate destination modifier for use with ET3 ambulance claims. The Medicare Claims Processing Manual, Chapter 15, Section 30, states modifiers specific to Ambulance Service Claims explains how ambulance services should be billed and what modifiers should be used. The provider needed to bill with Modifier "RP" to show the enrollee was transported from their residence to the physician's office.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim was not submitted with the appropriate modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance response services provided to the enrollee on October 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an outpatient surgery provided on May 09, 
2022. 
 
You asked the Plan to reduce the copayment for an outpatient surgery. You say that you would like a 
reconsideration of the cost-share. You say that you are 80 years old and it would be difficult for you to come up 
with $822.50. 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 $295 
copayment for outpatient surgery. 
 
You have been asked to pay a $295 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery 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 copayment for an outpatient 
surgery provided on May 09, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the continued skilled nursing facility (SNF) services provided from 
February 21, 2022, to February 25, 2022. 
 
You asked the Plan to pay for SNF care. You say that you are on social security income and cannot pay this 
bill. The Plan denied your request. The Plan says that you were both informed of the financial obligation and 
did not meet skilled needs as of February 21, 2022. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before February 20, 2022. Specifically, the NOMNC that was issued was not signed. The Plan must 
pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed 
and proper notice is issued. Therefore, we decided that the Plan has to pay for the continued skilled nursing 
facility (SNF) services provided from February 21, 2022, to February 25, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 are requesting reconsideration of approval for 
inpatient rehabilitation services due to fracture of your right femur. The Plan denied your request. The Plan 
says based on Medicare guidelines the inpatient rehabilitation facility services you are requesting do not meet 
the requirements for approval. 
 
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 you were admitted for surgical repair of a hip fracture after a fall. Medical 
problems are stable. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmological services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve ophthalmological services. The Plan denied your request. The Plan says the 
service requested may be obtained from an in-network provider. It has been confirmed there is a provider 
available and within the Medicare allowable distance and time. 
 
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 
ophthalmological services to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services (T1019). 
 
You asked the Plan to pre-approve personal care services. You say that you are a needing person. You say that 
you have a foot problem. You also say that you have pain. The Plan denied your request. The Plan says 
personal care services are not a covered benefit. 
 
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 personal care 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 personal 
care services (T1019).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on February 
25, 2022. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral.  If no bilateral code is provided and the 
condition is bilateral, assign separate codes for both the left and right side.  If the side is not identified in the 
medical record, assign the code for the unspecified side.  
 
We looked at the file and Medicare rules. In this case, the claim was billed with diagnosis codes M17.11 
(Unilateral primary osteoarthritis, right knee) and M17.12 (Unilateral primary osteoarthritis, left knee). As a bilateral code exists for this diagnosis, it is inappropriate to list each unilateral diagnosis code separately. Based 
on this information, we decided that Medicare rules for coverage of the DME have not been met. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment (DME) provided on February 25, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is currently trach to vent and 
needs continued vent weaning in the LTACH. The enrollee has had altered mental status during the stay. The 
Plan denied your request. The Plan says based on the information provided regarding the enrollee's medical 
condition, they do not meet long term acute care hospital level of care and the needs. The enrollee's needs are 
determined to be best met at an alternate level of care, such as admission to skilled nursing facility or continued 
approval at the higher level of 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 setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are 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 the LTACH services.
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 are requesting inpatient rehabilitation for the 
enrollee. The Plan denied your request. The Plan says that the enrollee's needs can be met at a lower level of 
care such as home health, long-term care facility, or part-time skilled services. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214), triamcinolone acetonide (J3310), and 
injection (20610) provided on February 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the enrollee presented their Traditional 
Medicare card at the time the services were rendered. You also say that you were not aware that authorization 
was needed at the time. The Plan denied your request. The Plan says prior authorization was not obtained 
before the services were rendered to the enrollee. 
 
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 provider in this case is not a network provider with the Plan. 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 office visit (99214), triamcinolone acetonide (J3310), and 
injection (20610) provided on February 21, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99255 billed for date of service December 3, 
2021, to December 16, 2021. 
 
You asked the Plan to pay for procedure code 99255. You say that these services are supported as billed. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99255 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99255 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99255 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99255 billed for date of service December 3, 2021, to December 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from October 
7, 2020, to November 5, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a plan of care was not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 We find that a valid plan of care was not submitted for this episode of home health. 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 home health services provided to the enrollee from October 7, 2020, to November 
5, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport 
provided on May 5, 2022. 
 
You asked the Plan to pay for ambulance response and treatment with no transport. You say that your wife 
called 911 when your blood pressure was very high and you were disoriented and dizzy. You say that when the 
EMTs arrived they continued to monitor your blood pressure until it came down and you decided to seek 
medical attention with your physician instead of being transported to the emergency room. The Plan denied 
your request. The Plan says the service in question is not covered under the Member's contract under any 
normal circumstances. Ambulance response, no transportation provided is not a covered benefit by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 5, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment with no 
transport provided on May 5, 2022.