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. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 are medically stable and do not need physical medicine and rehabilitation 
(PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. At the level of function on March 7, 2022, you do 
not need intensive therapies, consisting of at least 3 hours of therapy per day at least five (5) days per week 
with multidisciplinary approach to daily therapy in an IRF. You need routine physical therapy (PT) and 
occupational therapy (OT). Your therapy needs can be addressed in an SNF. IRF admission is not medically 
necessary based on lack of medical complexity and lack of acute rehab nursing needs. Document does not 
support the necessity for admission to an IRF. Your rehabilitation needs can be met safely at a lower intensity 
and alternate setting such as in an SNF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor supplies (K0553) provided on 
October 14, 2021. 
 
You asked the Plan to pay for continuous glucose monitor supplies. You say that the items at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for 
continuous glucose monitors and related supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that billing more than 1 UOS per 30 days of code 
K0553 will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of continuous glucose monitor supplies have not been met. Specifically, the Plan has documented that 
another supplier has already billed 3 units for code K0553 on September 27, 2021. The claim at issue is 
therefore for more than 1 UOS per 30 days and is not reasonable and necessary. Therefore, we decided that the 
Plan does not have to pay for continuous glucose monitor supplies (K0553) provided on October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a patient lift for a toilet/tub, any type (E0625). 
 
You asked the Plan to pre-approve a patient lift for a toilet/tub, any type (E0625). You say that you need this 
item. The Plan denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
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 a patient lift for a toilet/tub, any type (E0625).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for laboratory services. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested provider is not in the plan's network. 
 
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 
an out-of-network referral for laboratory services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a urology specialist office visit and an 
ultrasound provided on August 2, 2021. 
 
You asked the Plan to waive the copayments for a urology specialist office visit and an ultrasound. You say 
that the results of the ultrasound were skewed because the doctor should have told you to stop taking your 
medication. The Plan denied your request. The Plan says you have been 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 $200 copayment per day for ultrasounds. The Plan contract also clearly says that you must pay a $50 copayment for 
a specialist office visit. 
 
You have been asked to pay the allowed amount of $182.99, which is less than a $200 copayment for an 
ultrasound. An ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. You have also been asked to pay a $50 copayment for a specialist office visit. A specialist 
office visit falls within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. 
You have been asked to pay a total of $232.99 ($182.99 copayment + $50 copayment = $232.99.) 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 copayments for a urology specialist office visit and an ultrasound provided on 
August 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 
27, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare says tests with no relation to a diagnosis for the health of the patient are not a 
covered benefit. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there were no specific clinical diagnoses for the obtained studies. Medicare says tests with no relation to 
a diagnosis for the health of the patient are not a covered benefit.  The review has determined that the the obtained lab studies were not medically necessary or reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on September 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of nerostimulator electrode 
(64555), and implantable neurostimulator (L8679). 
 
You asked the Plan to pre-approve a percutaneous implantation of nerostimulator electrode and implantable 
neurostimulator. You say that the service is medically necessary. The Plan denied your request. The Plan says 
this service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the implantation of central nervous system 
stimulators may be covered as therapies for the relief of chronic intractable pain is subject to the conditions 
listed in the Medicare Rules section of the letter. 
 
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 percutaneous implantation of 
nerostimulator electrode and implantable neurostimulator. Our reviewer says that the service is not medically 
necessary. Our physician reviewer found detailed documentation is not evident regarding that her current 
treatments including medications and injections are not providing symptomatic relief. Additionally, there is 
limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective 
and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. 
 
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 percutaneous implantation of nerostimulator electrode and implantable 
neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
percutaneous implantation of nerostimulator electrode (64555), and implantable neurostimulator (L8679).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a closed treatment of metacarpal fracture (26605) billed for 
date of service May 22, 2020. 
 
You asked the Plan to pay for a closed treatment of metacarpal fracture. You say that the services at issue were 
a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met because the provided records do not support the service billed. 
 
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, the CPT Code Manual definition of code 26605 is "Closed treatment of metacarpal fracture, single; 
with manipulation, each bone." 
 
We asked our coder 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 a closed treatment of metacarpal fracture. Our reviewer says 
that the billed service 26605 does not meet criteria for reimbursement in this case.  Our reviewer found that detailed documentation is not evident in the case record regarding any closed 
treatment having been provided for these fractures. No procedure notes were provided for this date. The 
treatment plan on May 22, 2020, was to follow up in one week for repeat X-rays and cast. Therefore, medical 
records do not support that the billed services were provided on May 22, 2020. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a closed treatment of metacarpal fracture have not been met. Therefore, we 
decided that the Plan does not have to pay for a closed treatment of metacarpal fracture (26605) billed for date 
of service May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology treatment services (CPT code 99214) to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you feel this facility's physician is 
more experience in the oncology treatment services. The Plan denied your request. The Plan says there are in-
network providers that can render the services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
oncology treatment services (CPT code 99214) to be provided by an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
November 8, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that a nurse put your 
intravenous (IV) needle in incorrectly. You also say you do not pay for something that you did not get or was 
broken. The Plan denied your request. The Plan says you have 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 $80 
copayment for an emergency room visit.  
 
You have been asked to pay a $80 copayment for an emergency room visit. An emergency room visit falls 
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 room visit provided on November 8, 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.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on IRF criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of your nursing, medical and rehabilitation needs require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. The documentation supports that you require at least 
three (3) hours a day, five (5) days a week, or fifteen (15) hours over seven (7) consecutive days, of therapy 
services. There is a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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 does not meet 
criteria. 
 
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's medical status does not require intensive physician and nursing 
oversight in an IRF. While the enrollee may benefit from additional multiple therapies, including physical and 
occupational therapy, the documentation does not reveal that the enrollee's functional level requires this therapy 
on an intensive IRF level. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee scooter/crutch substitute for the enrollee. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary for the enrollee's mobility 
limitation. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this request exceeds the enrollee's needs, and does not meet the criteria. Medicare does not pay for any 
items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to 
improve the functioning of a malformed body member. The documentation does not reveal a detailed physical 
examination revealing why the enrollee is unable to use standard crutches. The documentation does not reveal 
that the enrollee is able to use this device safely in the home, and that it will improve MRADLs participation in 
the home. 
 
  
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve knee scooter/crutch substitute for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral drug testing rendered on October 4, 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 services were not medically necessary. 
 
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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found more research is needed to support the 
use of oral fluid for on-site detection of recent drug use. The services are not supported and were not 
reasonable or medically necessary.  
We looked at this physician's review, the file, and Medicare rules. 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 oral drug testing rendered on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 26, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
 We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records do not show that the specimen was collected in a laboratory setting. 
This means that the claim was billed with the incorrect POS code. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on June 26, 2021.