Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception for office visits and treatment
to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an in-network exception for office visits and treatment to be provided by an
OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are
in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 in-network exception for office visits and treatment to be provided by an out-of-network (OON) provider.
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 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 waive the copayment for the inpatient hospital admission and
services provided from July 2, 2021, to July 6, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that you were unsatisfied with the
care provided during your hospital stay. The Plan denied your request. The Plan says this claim was processed
correctly, and your copayment was assessed in accordance with your contract.
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 $295
copayment for per admission for each medically necessary inpatient stay.
You have been asked to pay a $295 copayment for the inpatient care. 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 the inpatient hospital admission and services provided from July 2, 2021, to July 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from
November 30, 2021, forward.
You asked the Plan to pre-approve a continued inpatient psychiatric admission. You say that you require a
continued inpatient psychiatric admission. The Plan denied your request. The Plan says under Medicare
guidelines, the request is not medically necessary because the records received show that your condition has
improved, and you are no longer a threat to yourself or others.
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 a continued inpatient psychiatric
admission. Our reviewer says that a continued inpatient psychiatric admission from November 30, 2021,
forward is not medically necessary. Our physician reviewer found that you did not appear to require inpatient
mental health treatment beyond the date in question as you were not a danger to yourself or others and did not
have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active
treatment was taking place beyond the date in question. It did not appear that the services were reasonably
expected to improve your condition or for the purpose of diagnosis beyond the date in question. Based upon
review of the records provided for the admission, you do not meet the criteria for continued acute inpatient
mental health treatment for the dates in question of November 30, 2021, forward as you were not shown to be a
danger to yourself or others. You were not showing any auditory or visual hallucinations and were
cooperative/compliant with treatment while not showing any threats to 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 a continued inpatient psychiatric admission have not been met. Therefore, we
decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from November
30, 2021, forward.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the observation discharge day services provided on June 28, 2021.
You asked the Plan to pay for the observation discharge services. You say that this was medically necessary.
The Plan denied your request. The Plan says that this service was provided out of network and no authorization
was obtained.
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.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan has not provided a valid denial rationale in this case. This service was
denied since it was provided out of network without authorization. However, this claim is for the services of a
hospitalist on the last day of the patient's observation stay. Hospitalist providers are not required to obtain
authorization prior to treating a patient in the hospital setting. These are considered approved as part of the
overall facility stay. Therefore, we decided that the Plan has to pay for the observation discharge day services
provided on June 28, 2021.
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 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 does not require an
acute 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, and an intensive
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no
documentation of a need for an intensive rehabilitation 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
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 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 delay in therapy could result in the enrollee not being
able to return home at a safe functional level. The Plan denied your request. The Plan says an intensive
rehabilitation program 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 not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479) provided May 21, 2021.
You asked the Plan to pay for the genetic testing. You say that the testing was medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that SelectMDx testing is covered in males with
previous negative biopsy who are being considered for repeat biopsy.
We looked at the file and Medicare rules. There is no record of a previous negative biopsy. Based on this
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore,
we decided that the Plan does not have to pay for genetic testing (81479) provided May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room visit provided on May 28, 2021, with
reported primary diagnosis code S22.42XS.
You asked the Plan to pay for the emergency room visit as billed. You say that this should be paid. The Plan
denied your request. The Plan says the diagnosis code with a 7th character of S should not be coded first.
The Plan must follow Medicare rules. Medicare rules say that when reporting a sequela resulting from an
injury, the sequela must be billed first, then the injury to which the condition is a sequela. The 7th character of
S is used on the injury code.
The injury code with the 7th character of S was coded first which is not in accordance with billing rules.
Therefore, we decided that the Plan does not have to pay for the emergency room visit provided on May 28,
2021, with reported primary diagnosis code S22.42XS.
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 the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational
therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable
expectation that this enrollee 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 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 a group 3 power wheelchair with accessories (K0858,
E1028, E1002, E2311, E1012, E0953, E2607, E0955).
You asked the Plan to pre-approve the group 3 power wheelchair with accessories. You say that the power
chair is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet coverage
criteria for a group 3 power chair.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for
enrollees who have a mobility limitation that is due to:
1. A neurological condition;
2. Myopathy; or
3. Congenital skeletal deformity.
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3
power wheelchair with accessories (K0858, E1028, E1002, E2311, E1012, E0953, E2607, E0955).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital care (0120) provided
from July 20, 2021, to July 25, 2021.
You asked the Plan to waive the coinsurance for inpatient hospital care. You say that the services should be
covered as you were only inpatient for the last 3 days and were treated poorly. The Plan denied your request.
The Plan says that the coinsurance applied correctly based on the services provided.
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 $365
copayment for days 1 to 5 of Inpatient hospital care.
You have been asked to pay a $365 copayment for 5 days of inpatient hospital care (5 x $365 is $1,825). The
record shows that you were admitted into the inpatient facility on July 20, 2021, then discharged on July 25,
2021. 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 inpatient hospital care (0120) provided from
July 20, 2021, to July 25, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a driveline management kit (Q0508) provided on September
11, 2020, by an out-of-network provider.
You asked the Plan to pay for a driveline management kit. You say that the item at issue was a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not
been met.
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 driveline management kit (Q0508) provided on
September 11, 2020, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain
rendered on May 25, 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 are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the
head/brain rendered on May 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70450, 70486, 72125, 72128, 72131) provided January 25, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 codes 70450, 70486, 72125, 72128, & 72131 are not supported in the medical record. Specifically, the patient name and date of birth on the records does not match the patient details on the claim form. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (70450, 70486, 72125, 72128, 72131) provided January 25, 2021.
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 continued care in the short-term acute care hospital appears to be appropriate until
the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute
rehabilitation facility or a skilled nursing facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.