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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 3, 2022 to 
January 21, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
have cited disagreement with removing code N17.0 (Acute kidney failure with tubular necrosis). The Plan denied your request. The Plan says that there was insufficient clinical evidence and supportive documentation 
in the records available for review to substantiate the coding of acute tubular necrosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 080. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the documentation does not indicate that the treatment ordered by the treating medical providers supported 
a diagnosis code of N17.0 (Acute kidney failure with tubular necrosis). In this case, the documentation does not 
consistently and completely support the assigned secondary diagnosis code. The decision to remove the 
secondary diagnosis code and adjust the DRG is upheld.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 3, 2022 to January 21, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve the dental implants. You say that dentures do not fit in your mouth properly. 
You also say that you need the bottom dental implants. The Plan denied your request. The Plan says this 
service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental implants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression device to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compression device. You say that you are requesting 
reconsideration. The Plan denied your request. The Plan says the enrollee must receive their care from a 
network provider (for more information about this, see Section 2 in Chapter 3). In most cases, care the enrollee 
receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
covered. This means that the enrollee will have to pay the provider in full for the services furnished. 
 
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 
pneumatic compression device to be provided by an out-of-network (OON) provider.
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 the services are medically necessary and beneficial 
to the enrollee. The Plan denied your request. The Plan says the enrollee can receive the care needed in another 
setting, such as at home, in a long-term care facility, or other outpatient setting. 
 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 that the enrollee is functioning at a home care level. Intensive rehabilitation is not 
indicated for the enrollee's chronic functional loss. 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require daily skilled nursing or skilled therapy services. You do not 
meet the 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept basivertebral nerve ablation procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is a proven treatment which is 
covered per a Medicare Local Coverage Determination (LCD). The Plan denied your request. The Plan says 
this procedure is considered experimental at this time. 
 
Please note: Maximus did review the LCD cited by the appellant, and we find that the rule is not controlling 
for the State of Florida. As such, we used general medical necessity in making our determination.  
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental at this time. More research is needed to 
support medical necessity. 
 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept basivertebral nerve ablation procedure.
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 the enrollee has very restricted mobility and needs a 
higher level of care then they can receive at home. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare Criteria for skilled nursing facility care. 
 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has no identifiable skilled nursing service needs. There are identifiable 
skilled therapy service needs, however the enrollee does not require skilled nursing or therapy services on a 
daily basis. The 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the PT services. You say that your current treatment is not effective, and 
you would like to see this provider since they offer additional therapy services. The Plan denied your request. 
The Plan says network providers are available to render necessary 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 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 
physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ReActiv8 restorative neurostimulation device. 
 
You asked the Plan to pre-approve the ReActiv8 restorative neurostimulation device. You say that the enrollee 
has tried all other treatment options. The appellant says that the documentation provided supports the need for 
the item in dispute. The Plan denied your request. The Plan says the requested device is considered 
experimental/investigational. 
 
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 ReActiv8 restorative 
neurostimulation device. Our reviewer says that the requested ReActiv8 restorative neurostimulation device is 
not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited 
published, large-scale, long-term peer-reviewed literature that shows the ReActiv8 restorative neurostimulation 
to be an effective and/or safe treatment for the noted pathology. Additionally, detailed documentation is not 
evident as to why he cannot continue with the Sprint peripheral nerve stimulation (PNS), since he is having 
good response to this device. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception.  
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 ReActiv8 restorative neurostimulation device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the ReActiv8 restorative neurostimulation device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve NeoTYPE colorectal tumor panel Next Generation 
Sequencing (NGS). 
 You asked the Plan to pre-approve NeoTYPE colorectal tumor panel NGS. You say that the records provided 
support the need for the testing services which remain in dispute. The Plan denied your request. The Plan says 
the NeoTYPE colorectal tumor panel is not an FDA-approved test. 
 
The Plan follows Medicare rules. Medicare rules say that diagnostic laboratory testing using NGS must have 
FDA approved or cleared indication for use in that patient's cancer.  
 
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 NeoTYPE colorectal tumor panel NGS. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee 
has a diagnosis of poorly differentiated stage IV adenocarcinoma of the sigmoid colon, with extensive 
peritoneal metastatic disease. The NeoTYPE colorectal tumor panel Next Generation Sequencing does not have 
an FDA-approved or FDA-cleared indication for use in this 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 NeoTYPE colorectal tumor panel NGS have not been met. Therefore, we 
decided that the Plan does not have to pre-approve NeoTYPE colorectal tumor panel Next Generation 
Sequencing (NGS).
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's best chance of a quicker 
recovery will be an admission to an LTACH. You say that at an LTACH the enrollee can receive the 
individualized care plan and aggressive treatment needed to get them prepared for the next level of care. The 
Plan denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee can 
get the services they need in the current hospital setting. 
 
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 that the enrollee is improving but still is not stable and only requires short-term acute 
care at the current facility. The enrollee does not require services at the LTACH that are not already available at 
the current facility. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated seat cushion and back support 
(E2609, E2617). 
 
You asked the Plan to pre-approve a custom fabricated seat cushion and back support. You say that these items 
are medically necessary. The Plan denied your request. The Plan says custom seating is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the enrollee must meet criteria for coverage as 
described in the 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 a custom fabricated seat cushion and back support. Our reviewer says that the items are not medically necessary. Our physician reviewer found that 
based on the medical records provided there are differing opinions from different physical and occupational 
therapists with regard to the necessity of the custom fabricated seat cushion and back support as opposed to a 
prefabricated cushion and support. No medical notes from the enrollee's treating physician or advanced practice 
provider are provided documenting examination of the enrollee to support the need for the custom fabricated 
seat cushion and back support as opposed to a prefabricated cushion and support. 
 
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 custom fabricated seat cushion and back support have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a custom fabricated seat cushion and back 
support (E2609, E2617).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on September 
13, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you do not agree with paying 
the 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 $250 
copayment for ambulance services, per one-way trip. 
 
You have been asked to pay a $250 copayment for ambulance services. This item/service falls within the 
ambulance services, per one-way trip 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 September 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided on 
November 16, 2022. 
 
You asked the Plan to pay for code D0431. You say that since this was a cancer check would it not be covered 
under the medical portion of your policy. The Plan denied your request. The Plan says this service is not 
covered under the Plans dental benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
adjunctive pre-diagnostic test (D0431) provided on November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 29, 2022. 
 
You asked the Plan to pay for dental services. You say that these services should be paid. The Plan denied your 
request. The Plan says the enrollee is not enrolled in a supplemental dental benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services provided on 
March 29, 2022.