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

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from June 18, 2020, to
June 21, 2020, and billed under diagnosis related group (DRG) 871.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial for a lack
of medical records in the file. The Plan requested a reopen and submitted the required medical records.
Our Medical Director looked at the case file and the reopen request. At issue is whether the billed DRG 871:
Septicemia or severe sepsis without mechanical ventilation greater than 96 hours with major complication or
comorbidity (MCC), is supported by the medical records. The medical records show the enrollee was a then 80-
year-old man with a history of COPD, atrial fibrillation, hypertension, and hyperlipidemia, who was admitted
to the hospital on June 18, 2020, with listed diagnoses of sepsis and acute pyelonephritis. Wheezing was noted,
and the enrollee was diagnosed COPD exacerbation with acute respiratory failure with hypoxia. The enrollee
was treated with 2 liters of oxygen. Blood pressure and respiratory rate were normal to elevated. WBC
elevated. Urine culture suggested contamination. Blood cultures were negative. The sepsis criteria cited were
fever, tachycardia, tachypnea, leukocytosis, with a source being likely urinary. Sepsis has been defined by a
2016 SCCM/ESICM task force as life-threatening organ dysfunction caused by a dysregulated host response to
infection (Sepsis-3) as evidenced by organ dysfunction. The clinical documentation provided in the reopen
request supports that there is insufficient support for DRG 871: Septicemia or severe sepsis without
mechanical ventilation greater than 96 hours with major complication or comorbidity.
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 care provided to the enrollee from June 18, 2020, to June 21, 2020, and billed under diagnosis
related group (DRG) 871.
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 IRF care is medically necessary, and the enrollee 
is motivated to do therapy. The Plan denied your request. The Plan says authorization denied because the IRF 
care is not medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled 
nursing facility (SNF) care. 
 
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 is medically stable and does not need close physician supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical 
conditions. There are no acute nursing needs identified or documented. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the periodic oral evaluation - 
established patient (D0120), intraoral - complete series of radiographic images (D0210), and prophylaxis - 
adult (D1110) provided November 1, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the periodic oral exam, complete series of x-rays and 
dental cleaning. You say that you would have declined having the x-rays if you had been told they would not 
be covered. The Plan denied your request. The Plan says these services have processed correctly according to 
your OON benefits. 
 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. The Plan covers the periodic 
oral exam, complete series of x-rays and dental cleaning with a $0 copayment when provided in-network. If 
you choose to see an out-of-network dentist, you might be billed for charges above what the Plan pays.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that the full allowed 
amount for the services was covered by the Plan. You have been asked to pay the difference between the 
allowed amount and the total cost charged by the OON provider.  Therefore, we decided that the Plan does not 
have to provide additional payment for the periodic oral evaluation - established patient (D0120), intraoral - 
complete series of radiographic images (D0210), and prophylaxis - adult (D1110) provided November 1, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided the enrollee does not meet the criteria for May 31, 2022 forward as this enrollee was not shown to be a danger to herself or others. There were no delusions, auditory or visual hallucinations noted. 
She was cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on January 7, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the nursing home is responsible to 
obtain prior authorization for their patients, which should cover medical treatments by the provider. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan, and authorization was not 
obtained prior to the services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
January 7, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (77523). 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says the services at issue are 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 proton beam radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient prospective, long-term clinical data available to 
determine whether or not proton beam radiation therapy for prostate cancer is superior, inferior or equivalent to 
external beam radiation therapy, intensity-modulated radiation therapy, brachytherapy with regards to safety 
and efficacy. The most recent American Urological Association guidelines state that proton beam radiation 
therapy offers no clinical advantage over other forms of definitive treatment. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy (77523).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a positron emission tomography (PET) 
scan provided on January 10, 2022. 
 
You asked the Plan to waive the coinsurance for the PET scan. You say that you thought this was covered as 
part of your surgical procedure. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for radiological diagnostic services, such as PET scans.  
 
You have been asked to pay $291.17, which is less than 20% of the allowed amount for the PET scan 
($1,470.43 allowed amount x 20% coinsurance = $294.09). The PET scan falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 coinsurance for a positron emission tomography (PET) scan provided on January 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that given your initial injection provided relief for only 3 weeks, 
criteria set forth by Medicare for a repeat injection has not been met. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The most recent 
epidural steroid injection was on May 9, 2022, and it provided 20 to 30% relief of pain. Our physician reviewer 
found that your condition does not meet Medicare criteria for an epidural steroid injection. 
 
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 pre-approve an epidural steroid injection.
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 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 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 there are no services available at the LTACH that you require that are not available at 
the health care setting being offered by the health plan. The health plan has approved ongoing care in the 
current acute care facility. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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: 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 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 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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be 
clinically advantageous at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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: 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 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 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 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 health plan has approved ongoing care 
in the current acute care facility. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 
  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that massage therapy visits were approved and 
encouraged by your primary doctor, your spine doctor and your physical therapist to treat painful muscle 
spasms in your back. The Plan denied your request. The Plan says massage therapy is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory testing provided on September 
21, 2021. 
 
You asked the Plan to waive the copayment for laboratory testing. You say that you don't have a copayment. 
The Plan denied your request. The Plan says the copayment has been applied 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 $15 
copayment for laboratory tests, non-radiological diagnostic tests, flat film X-rays, and ultrasounds. 
 
You have been asked to pay a $15 copayment for laboratory testing. Laboratory tests fall within the laboratory 
tests, non-radiological diagnostic tests, flat film X-rays, and ultrasounds 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 laboratory testing provided on September 21, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
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 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 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 there are no services at the LTACH that you require that are not already available and 
covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically 
advantageous at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after June 2, 2022. 
 
You asked the Plan to pre-approve SNF care after June 2, 2022. You say that the continued admission to a SNF 
is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is not 
medically necessary. 
 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care after June 2, 2022. Our 
reviewer says that continued daily skilled services are not necessary. Our physician reviewer found the 
documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing 
SNF need. Your functional level does not require continued skilled therapy services with the specialized skill, 
knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and 
reasonable treatment in a 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 SNF care after June 2, 2022, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care after June 2, 2022.