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 enrollee requires a higher quality of 
care and nursing care due to her wound vac. The Plan denied your request. The Plan says the records do not 
show that the enrollee needs ongoing care that can only be provided in a hospital setting or that the enrollee's 
doctors expect they will get better with LTACH care. The Plan says that the enrollee's continued care needs 
include therapy, and a palliative care consult was placed. The Plan says that when the enrollee is ready to leave 
the hospital, they can safely receive this care in another setting. 
 
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 the enrollee was admitted to the acute care hospital with acute respiratory failure, a 
COVID-19 infection, and urinary tract infection, complicated by encephalopathy, acute kidney injury, and 
severe wounds. She was treated with antibiotics, oxygen support, and wound care. Recent notes describe the 
enrollee as now tolerating room air and is still requiring wound vac and basic wound care. Palliative care was consulted due to poor prognosis. The enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be administered at the current facility until more stable 
and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not 
already available at the current facility. Transfer to the LTACH is not medically necessary at this time as it 
would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
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 the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary for the enrollee 
to receive LTACH care and they fully meet the criteria. The Plan denied your request. The Plan says the 
enrollee does not need daily complex wound care that needs intensive nursing care or on-site specialty services. 
The enrollee does not need daily complex wound care or frequent dressing changes. Based on the enrollee's 
medical condition and treatments, they will not need this level of service for 25 or more days. Based on the 
clinical information received, the enrollee does not meet the guidelines for long-term acute care services. 
 
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 that the enrollee appears to still be somewhat unstable for transfer but is improving 
and should only require short-term additional acute care services that can safely be administered at the current 
facility until more stable and appropriate for a lower level of care. The enrollee does not require services at the 
LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not 
medically necessary at this time as the enrollee is not stable for transfer yet, and as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended. 
 
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 the LTACH services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a therapy visit provided on May 03, 2022, 
May 10, 2022, May 11, 2022, May 12, 2022, and May 26, 2022. 
 
You asked the Plan to waive the copayments for a therapy visit. You say that this provider left without notice, 
and now you need to find a new provider. This is why you would like the copayments waived. The Plan denied 
your request. The Plan says the copayments that were applied were correct. 
 
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 $40 
copayment for Medicare covered individual or group therapy visit ($40 x 5 visits = $200).  
 
You have been asked to pay a total $200 copayment for therapy visits. A therapy visit falls within the 
Outpatient Mental Health Care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for a 
therapy visit provided on May 03, 2022, May 10, 2022, May 11, 2022, May 12, 2022, and May 26, 2022.  
 Maximus read your letter and knows that you may have a quality of care concern. Maximus 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional routine transportation trips 
 
You asked the Plan to pre-approve 24 additional trips. You say that the requested additional trips are a medical 
necessity for you. The Plan denied your request. The Plan says additional trips are not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 24 additional routine transportation trips
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel provided on August 20, 2020. 
 
You asked the Plan to pay for the general health panel. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
provided on August 20, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the interrogation device evaluation provided on March 17, 2022. 
 
You asked the Plan to pay for the services provided. You say that the claim is coded correctly. The Plan denied 
your request. The Plan says that the diagnosis is inconsistent with the procedure. 
 
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. 
 
In this case, the CPT Cod Manual definition of code 93290 is interrogation device evaluation (in person) with 
analysis, review and report by a physician or other qualified health care professional, includes connection, 
recording and disconnection per patient encounter; implantable cardiovascular physiologic monitor system, 
including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and 
external sensors.  
 
We find that CPT code 93290 was billed with diagnosis code I5.5, ischemic cardiomyopathy. The Plan did not 
provide any Medicare rules that indicate this diagnosis does not support medical necessity of the services. 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 interrogation device 
evaluation provided on March 17, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the extra-spinal chiropractic treatment (98943) and the electrical 
stimulation (G0283) provided on May 25, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that these services are not payable as you have 
exhausted the allowable chiropractic benefit. 
 
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. Specifically, the Plan contract states that 30 visits each calendar year are covered 
with a licensed chiropractor for additional services. The Plan has stated that the enrollee has exhausted the 
allowable benefit as 30 non-Medicare covered chiropractic services have been previously approved in the year 
2022. However, the Plan has not provided proof of the approvals/payments for these chiropractic services; 
therefore, we must find in your favor. Therefore, we decided that the Plan has to pay for the extra-spinal 
chiropractic treatment (98943) and the electrical stimulation (G0283) provided on May 25, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 49999) provided to the 
enrollee on December 8, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says plication of the diastasis recti was necessary to successfully complete repair of the ventral hernia, 
and this procedure is therefore incidental to the hernia repair (CPT code 49561) and may not be billed as a 
separate procedure. 
 
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 49999 is "Unlisted procedure, abdomen, peritoneum and 
omentum." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the record indicates 
that the enrollee underwent plication of the diastasis recti during repair of a ventral hernia. The record provided does not establish that an unlisted procedure of abdomen, peritoneum and omentum was performed. There is a 
more precise code to describe the reported service. The elements of the coverage criteria are not satisfied. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure code 49999) provided to the enrollee on December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the patient's records do not show that it is safe for them 
to leave the hospital. Their current care includes management breathing, heart failure exacerbation, chronic 
obstructive pulmonary disease (COPD) and diabetes. When their care is done and it's safe for them to be 
discharged, they can safely receive this care in another setting such as Facility (SNF) or at home with home 
health services or outpatient setting if appropriate. 
 
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 the patient is a 71 year old female who was admitted to the acute care hospital with 
worsening shortness of breath following recent admission for congestive heart failure/pneumonia/COPD 
exacerbation. She was treated with oxygen support, Lasix, dressing changes to chronic leg ulcers, BiPAP, and 
steroids. Recent notes describe the patient as now requiring Bumex, still on BiPAP at night and as-needed and remaining on steroids with persistent severe hypercapnia. The patient appears to be still somewhat unstable and 
requires short-term additional acute care hospital services that can be safely administered at the current facility 
until more stable and appropriate for a lower level of care. The patient does not require services at the LTACH 
that are not already available at the current facility. There are no services at the LTACH that the patient 
requires that are not already available and covered at the current facility. Transfer to the LTACH is not 
medically necessary as the patient is not yet stable enough for transfer, and as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended.  
 
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 the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will require another three to 
four weeks transition from acute illness. The Plan denied your request. The Plan says based on Medicare 
guidelines, the long term acute care hospital services you are requesting do not meet the requirements for 
approval. 
 
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 the enrollee was admitted to the acute care hospital with pneumonia complicated by 
bleeding from trach, deep vein thrombosis and end-stage renal disease. Antibiotics were continued, given trach 
care and Eliquis continued. Recent notes describe the enrollee as hemodynamically stable, tolerating oxygen 
support via trach collar. The enrollee appears to be stable and improving and should only require short term 
additional acute care hospital services that can safely be administered at the current facility until more 
appropriate for a lower level of care.  The enrollee does not require services at the LTACH that are not already available at the current 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 the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules have not been 
met because the requested services are experimental/investigational. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. More research is needed to demonstrate 
the safety and effectiveness of the procedure. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ophthalmological examination and 
evaluation (92014) provided on March 17, 2022. We also decided that the Plan does not have to pay for a 
refraction and any necessary prescription of lenses (92015). 
 
You asked the Plan to waive the copayment for an ophthalmological examination and evaluation (92014). You 
also asked the Plan to pay for a refraction and any necessary prescription of lenses (92015). You say that you 
expected not to be charged as this service was because of the previous provider's error. The Plan denied your 
request. The Plan says you were charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each eye exam to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $50 copayment for an ophthalmological examination and evaluation (92014). an 
ophthalmological examination and evaluation (92014) fall within vision care benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan.  
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers refractions are only when performed during a routine vision exam. 
 
We looked at the file and the Plan's rules. The Plan covers refractions are only when performed during a 
routine vision exam. The record shows that this was not a routine eye exam. Based on this information, we 
decided that the Plan's rules for coverage of a refraction and any necessary prescription of lenses (92015) have 
not been met. Therefore, we decided that the Plan does not have to waive the copayment for an 
ophthalmological examination and evaluation (92014) provided on March 17, 2022. We also decided that the 
Plan does not have to pay for a refraction and any necessary prescription of lenses (92015) also provided on 
March 17, 2022.