Persius/hicric huggingface dataset:
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 requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 admission is not medically necessary. Our physician reviewer found there is no 
documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving 
appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are 
not available at the acute care hospital where he is currently receiving care. There are no services available at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) and sedimentation rate, 
erythrocyte (85652) provided November 23, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the medical records provided support the 
necessity of the services in dispute The Plan denied your request. The Plan says does not meet Medicare 
NCD/LCD criteria. This service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we find that CPT code 85652 and 80050 is not supported in the medical record. Specifically, CPT 
code 80050 is excluded by Medicare and not payment. CPT code 85652 is not a Medicare benefit for the 
diagnoses listed and is done for screening purposes. Medicare says screening services with no relation to a 
medical diagnosis of disease for the health of the patient are not a benefit. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided 
that the Plan does not have to pay for the general health panel (80050) and sedimentation rate, erythrocyte 
(85652) provided November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on February 16, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on January 11, 2022. 
 
You asked the Plan to pay for critical care services (99291). You say that the documentation supports the 
evaluation and management level of care billed and the codes are payable as billed. You say that the denial 
should be reviewed. The Plan denied your request. The Plan says the documentation submitted does not 
support a critical care visit of 30-74 minutes was performed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
  We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not document 
the time spent on critical care services as required by the CPT code billed. Based on this information, we 
decided that Medicare rules for coverage of critical care services (99291) have not been met. Therefore, we 
decided that the Plan does not have to pay for critical care services (99291) provided on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft at time of implant placement (D6104 x 2), 
and surgical access to an implant body (D6011 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that the requested services were medically 
necessary. The Plan denied your request. The Plan says the requested services are not listed as covered. 
 
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 bone graft at time of 
implant placement and surgical access to an implant body are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve a bone graft at time of implant placement 
(D6104 x 2), and surgical access to an implant body (D6011 x 2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colostomy or skin level cecostomy (44320) and drainage 
of peritoneal abscess (49020) provided on August 31, 2021. 
 
You asked the Plan to pay for the colostomy or skin level cecostomy (44320) and drainage of peritoneal 
abscess (49020). You say that both CPT codes are clearly described in the operative note and the claim should 
be reviewed for payment. The Plan denied your request. The Plan says there are more appropriate codes for the 
services performed. 
 
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 44320 is colostomy or skin level cecostomy. The CPT 
Code Manual definition of code 49020 is drainage of peritoneal abscess or localized peritonitis, exclusive of 
appendiceal abscess, open. 
 
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 the colostomy or skin level cecostomy (44320) and drainage 
of peritoneal abscess (49020). Our reviewer says that the medical documentation does not support the use of 
CPT codes 44320 and 49020. Our reviewer found that the documentation clearly describes a laparoscopic skin 
level cecostomy procedure and a laparoscopic aspiration of cavity cyst. The procedure codes chosen were for 
open procedures, not laparoscopic; therefore, the coding is not accurate. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the colostomy or skin level cecostomy (44320) and drainage of peritoneal 
abscess (49020) have not been met. Therefore, we decided that the Plan does not have to pay for the colostomy 
or skin level cecostomy (44320) and drainage of peritoneal abscess (49020) provided on August 31, 2021.
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. You say that the requested Aranesp is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Retacrit or Procrit first. 
 
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 reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the available documentation does 
not support that Retacrit or Procrit have been tried and failed. The documentation does not support that Retacrit 
or Procrit would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed on December 15, 2021. 
 
You asked the Plan to pay for procedure code 99053. You say that the enrollee was seen in the emergency 
room by the physician for a medically necessary procedure. You say that the claim should be reprocessed. The 
Plan denied your request. The Plan says procedure code 99236 was reprocessed for payment. The Plan also 
says procedure code 99053 has a status indicator of B and is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99053 billed on December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 14, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans
denial for insufficient information on the separate processing of some of the codes on the claim. The Plan
requested a reopen and provided the outcome of all codes processed to date.
The Plan states that codes 87150, 87801, and U0004 were denied for no records having been submitted for
review. Records were then submitted and codes 87150, 87801, and U0004 re-processed and a denial was issued
on January 12, 2022, under a separate claim. A Provider Remittance Advice was sent to the provider with
appeal rights. A copy of that Provider Remittance Advice was submitted with the reopen. 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. Based on a new independent review, the
Plan is not required to pay for codes 87150, 87801, U0004 and 87486.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental extractions provided on July 30, 2021, prior to hip
replacement surgery.
You asked the Plan to pay for these dental extractions. You say that you needed dental clearance for hip
replacement surgery which included these extractions. The Plan denied your request. The Plan says while these
extractions may have been necessary, they are not a covered dental benefit. Maximus overturned the Plans
denial stating removal of these teeth were medically reasonable and necessary to provide the best
outcome of the hip replacement surgery and to avoid infection. The Plan requested a reopen and stated that the
issue was not medical necessity but that these dental services were not a covered benefit.
The Plan is correct in this case. Medicare generally does not cover dental services. However, the Plan offered a
dental benefit that exceeded Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
While it is understood it was beneficial to have these extractions done to avoid infection, they still fell under
the supplemental dental benefit rules. You did not have prior authorization for these extractions, and they were
not covered under your dental benefit at the time of service. Therefore, we decided that the Plan does not have
to pay for dental extractions provided on July 30, 2021, prior to hip replacement surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for root canal therapy retreatment procedure (D3348) 
provided on February 2, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were misinformed about balance 
billing. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay $1,048, which is the difference between the out-of-network providers charges and 
the Plans payment ($1,825 total billed amount - $777 allowed amount = $1,048). You have also been asked to 
pay $388.50, which is 50% coinsurance of the allowed amount for the retreatment procedure ($777 allowed 
amount x 50% coinsurance = $388.50). You have been asked to pay a total of $1,436.50 ($1,048 + $388.50 = 
$1,436.50). This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for root canal therapy retreatment procedure 
(D3348) provided on February 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a recent randomized clinical trial 
found that continuous monitoring for atrial fibrillation with an ILR (followed by treatment with oral 
anticoagulation if atrial fibrillation was detected) was not superior to usual care in reducing stroke or systemic 
embolism among patients at high risk of stroke but without a known prior history of atrial fibrillation. At this 
time, insertion of an ILR would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation 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 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: 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation 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 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 that the enrollee does not meet criteria for IRF 
admission. 
 
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 clinical documentation shows that the enrollee has active medical comorbidities that would benefit from 
close medical supervision on an inpatient basis. In addition, Cerebrovascular accident (CVA) is an IRF 
compliant diagnosis and evaluating therapist state that the enrollee requires intense therapy. IRF criteria have 
been met and the requested admission to an IRF is medically reasonable and 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bronchial valve insertion to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON a bronchial valve insertion. You say that you requested an 
exception due to the uniqueness of the requested procedure. You say that no other facility or doctor who is 
reasonably located can perform the needed procedure. The Plan denied your request. The Plan says there are in-
network doctors within a reasonable distance of the enrollee's location who can provide the service requested. 
 
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 shown that they have 
network providers available who can provide the bronchial valve insertion services at issue in this appeal. 
These providers are located within a reasonable distance of the enrollees home. We found no exception that 
would require the Plan to pre-approve OON services. Therefore, we decided that the Plan does not have to pre-
approve a bronchial valve insertion to be provided by an out-of-network (OON) provider.