Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from March 17, 2022, to April 11, 
2022. 
 
You asked the Plan to pay for the home health services. You say that the final claim complies with the 
guidelines. The Plan denied your request. The Plan says that a request for anticipated payment (RAP) was not 
submitted timely. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Plan denied services based on guidelines for services provided in 2021. 
Home health agencies are not required to submitted RAP payments for services provided in 2022. The Plan 
offered no other Medicare rule in their decision. The Plan has not made reasonable and diligent efforts to gather 
and forward to us information regarding their decision to deny your request.  Therefore, we decided that the 
Plan has to pay for the home health services provided from March 17, 2022, to April 11, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: 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 requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the documentation shows that the enrollee has complex functional impairments and active medical 
comorbidities thus the complexity of the enrollee's documented nursing, medical and rehabilitation needs 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Evaluating 
therapists (physical therapy, occupational therapy and speech therapy) all recommend ongoing skilled therapy 
in an inpatient rehabilitation setting thus would be expected to tolerate an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0562) and sleeves
(E0667) provided to the enrollee on June 14, 2022, by an out-of-network (OON) provider.
You asked the Plan to pay for the pneumatic compression device and sleeves. You say that the enrollee was
referred to your facility by their treating physician. The Plan denied your request. The Plan says that the
rendering provider is an out of network provider and there was no approved authorization.
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 the pneumatic compression device (E0562) and
sleeves (E0667) provided to the enrollee on June 14, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the fecal occult blood test for colorectal cancer screening (G0328) provided on September 12, 2022.
You asked the Plan to pay for the fecal occult blood test for colorectal cancer screening. You say that this was medically necessary. The Plan denied your request. The Plan says that this is only covered once every twelve months.
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 are covered for one Guaiac-based fecal occult blood test (gFOBT) or Fecal immunochemical test (FIT) every 12 months. The
Plan has already paid for one of these services on February 9, 2022. Therefore, we decided that the Plan does not have to pay for the fecal occult blood test for colorectal cancer screening (G0328) provided on September 12, 2022.
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 enrollee has right hip pain, the enrollee had hip 
replacement on 03/15/2023 and has had one dislocation since that time was discharged from rehab on 
04/01/2023 and has been unable to walk since then. The enrollee also has significant shortening to right leg 
upon arrival to ED. The Plan denied your request. The Plan says there is a lack of medical necessity for 
admission to an acute IPR unit. The enrollee would be equally well served at an alternative level of care such as 
discharge to SNF with skilled therapies. 
 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 continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that she 
would meet criteria for admission to an acute 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2377, E2313, E2311) and 
power seat elevation (E2300). 
 
You asked the Plan to pre-approve the upgraded electronics and power seat elevation. You say that the 
requested items are medically necessary. The Plan denied your request. The Plan says that the upgraded 
electronics are not medically necessary to control the power options through the joystick. The Plan also says 
that the power seat elevation feature is not primarily medical in nature and is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are medically necessary when it 
is necessary to control the power options through the joystick. The rules also say that the power seat elevation 
feature is not covered as it is not primarily medical in nature. 
 
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 upgraded electronics and power seat 
elevation. Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that you 
have adequate strength in your upper extremities to manage the standard control switches. 
 
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 upgraded electronics have not been met. The power seat elevation feature 
(E2300) is not covered as it is not primarily medical in nature. Therefore, we decided that the Plan does not 
have to pre-approve the upgraded electronics (E2377, E2313, E2311) and power seat elevation (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the group 2 standard power wheelchair (PWC) (K0842) 
and accessories (E0955, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2603) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the PWC and accessories. You say that the enrollee cannot travel to obtain 
this item. The Plan denied your request. The Plan says this item is available in-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 
the group 2 standard power wheelchair (PWC) (K0842) and accessories (E0955, E1007, E1012, E1028, E2311, 
E2313, E2361, E2377, E2603) 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 allograft services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
service is unproven. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for pseudarthrosis after fusion or arthrodesis.  There is limited published, large-scale, long-term peer-reviewed literature that shows this requested allograft to 
be an effective and/or safe treatment for the noted pathology. Further studies are needed to demonstrate this 
request has beneficial outcomes compared with conventional treatment. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested ViviGen cell-based allografts, in this case, is not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve allograft services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to provide coverage for the acute inpatient hospital care. 
 
You asked the Plan to provide coverage for acute inpatient hospital care. You say that inpatient care is 
medically necessary. The Plan denied your request. The Plan says that an inpatient level of care is not 
medically necessary. 
 
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 provide coverage for acute inpatient hospital care. 
Our reviewer says that the documentation supports that the criteria for coverage of inpatient care are met in this 
case. Our physician reviewer found that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier emergency 
department and/or observation 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 been met. Therefore, we decided that the Plan 
has to provide coverage for the acute inpatient hospital care.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that medical record documentation has been 
submitted for review, as well as a letter of medical necessity by the provider. The Plan denied your request. 
The Plan says the records do not show failure of BiPAP. Your records show that BiPAP helped the enrollee in 
the hospital. The doctor has requested a NIV in AVAPS mode, which can be met by a BiPAP. The records also 
show that the enrollee did not use the Trilogy she had in the past consistently. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in targeted tidal volume, volume assured pressure support 
(TTV-VAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with average volume 
assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial and failure of a 
BiPAP device with AVAPS and a back-up rate. As stated in the Local Coverage Determination (L33800): 
"Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD 
policy will be denied as not 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on April 25, 2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the plan's denial. The 
Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan follows Medicare rules. The rules say that home health services under a plan of care are paid based on 
a 30-day period of care.   
 
In this case, the claim was not submitted for a 30-day period of care. As the claim was not submitted correctly, 
no payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for the home 
health services provided on April 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion procedure (22869). 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that you are requesting an appeal for 
current procedural terminology (CPT) 22869 lumbar decompression Vertiflex L4-L5. This is a covered benefit 
by Medicare. The Plan denied your request. The Plan says the procedure is considered experimental and 
investigational. There are not enough studies on Vertiflex Superion to show it is safe and effective. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found The Vertiflex device is experimental. More research is needed. 
 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex Superion procedure (22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and should be 
covered. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for intra-campus ambulance transport provided to the enrollee on March 2, 2022.
You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your request. The Plan says this claim should be billed to the facility from which the transport originated. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say intra-campus transfers are not separately payable under the Part B ambulance benefit. These claims should be submitted to the originating hospital for payment. Medicare rules for payment of this claim are not met. Therefore, we decided that the Plan does not have to pay for intra-campus ambulance transport provided to the enrollee on March 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health visits provided to the enrollee on July 7, 2022, by an out-of-network (OON) provider.
You asked the Plan to pay for the home health visits. You say that it was medically necessary to treat the enrollee. The Plan denied your request. The Plan says that the rendering provider is an OON provider and there was no approved authorization.
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 the home health visits provided to the enrollee on July 7, 2022, by an out-of-network (OON) provider.