Persius/hicric huggingface dataset:
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 admission to an IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF.  
 
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 rules say that Medicare will pay for an IRF admission when the services are 
reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary 
approach to providing rehabilitation. The enrollee must need active and ongoing treatment by more than one 
therapy discipline. One of the therapies must be physical therapy or occupational therapy. The enrollee must 
need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. 
This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at 
least five days per week. The review has determined 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. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. Note: if the enrollee does not 
require at least 3 hours a day/5 days a week, or 15 hours over 7 consecutive days, of therapy services but there 
are other indicators that this patient requires and can participate in a rehabilitation therapy program sufficient 
for this level of care, please provide particulars as to the indicators of intensity. There is not a reasonable 
expectation that this patient 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the psychotherapy visits provided by out-
of-network provider from May 23, 2023, to August 29, 2023. 
 
You asked the Plan to reduce the cost share for the psychotherapy visits. You say that you were told these 
charges would be removed due to a coding issue, and that you should only be charged a $10 copayment. The 
Plan denied your request. The Plan says this cost sharing was charged 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 there is a $490 
deductible that applies to out-of-network psychotherapy visits in an office setting. The Plan contract also says 
that you must pay 50% coinsurance after the deductible is met.  
 
The amount of $98.36 was applied to your deductible for the psychotherapy visits provided on May 23, 2023, 
June 29, 2023, and August 7, 2023. The remaining $44.92 of your deductible was applied to your visit on 
August 22, 2023, and the new allowed amount for this visit was $53.44 ($98.36 original allowed amount - 
$44.92 deductible = $53.44 remaining allowed amount). The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $490 deductible which applies to out-of-network psychotherapy visits 
in an office setting. This cost sharing is a contractual obligation that had not been met at the time the 
psychotherapy visits were received from May 23, 2023, to August 22, 2023. 
 
You have been asked to pay $26.72, which is 50% coinsurance of the allowed amount after the deductible was 
satisfied for the psychotherapy visit on August 22, 2023 ($53.44 remaining allowed amount x 50% = $26.72). 
You have also been asked to pay $49.18, which is 50% coinsurance of the allowed amount for the 
psychotherapy visit on August 29, 2023 ($98.36 allowed amount x 50% = $49.18). These services fall within 
the outpatient behavioral health care benefit category. This means 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 reduce the cost share for 
the psychotherapy visits provided from May 23, 2023, to August 29, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 31, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that this transport should be paid separately 
because it was an emergency. The Plan denied your request. The Plan says the enrollee was in a covered 
inpatient stay on the date of service, so no separate payment can be made for these ambulance services. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance transport from one hospital to another 
to receive specialized care that is not available at the facility there the patient is an inpatient is not separately 
payable.  Payment for these ambulance services is included in the PPS rate for the hospital. 
 
In this case, the enrollee was in a covered Part A stay from May 28, 2023, to June 2, 2023. According to the 
ambulance trip report, the enrollee was transported from the hospital on May 31, 2023, to a skilled nursing 
facility as part of a routine discharge. (This was not an emergency transport- the records show it was a routine 
discharge transport, and the patient was in no distress and no pain.) Because this transport occurred during the course of covered Part A stay, payment for this transport is considered part of the PPS payment, and no 
separate payment is allowed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services provided on May 31, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to provide SNF care. 
 
You asked the Plan to provide SNF care. You say that you need the SNF care to regain maximum function and 
if you cannot receive SNF services you are at risk. The Plan denied your request. The Plan says they have 
already covered 100 days of SNF care during this benefit period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from August 10, 2023, to 
December 27, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to provide SNF care.
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 you need this care to regain function. The Plan 
denied your request. The Plan says medical records do not support the need for an IRF admission and, your 
needs can be provided at another setting.  
 
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 medical, rehabilitation, and nursing needs does not require 
IRF care with an interdisciplinary approach to rehabilitative care. Your rehabilitation needs can be safely 
provided in an alternate setting.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination (x-ray) of the ankle (73610) 
provided on September 14, 2023. 
 
You asked the Plan to pay for the x-ray. You say that the service was billed correctly and should be paid. The 
Plan denied your request. The Plan says that CPT code 73610 cannot be billed separately because it is 
packaged into payment for CPT code 99283. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 73610 is not supported in the medical record. Specifically, code 73610 has a status 
indicator of Q1 in the Outpatient Prospective Payment System (OPPS). Q1 codes are packaged and are not 
separately paid when billed with another code with an OPPS indicator of S, T, or V. In this case, code 99283 
that was billed and paid on the same date of service has a status of J2 and V. Therefore, code 73610 is not 
separately paid. Based on this information, we decided that Medicare rules for coverage of the x-ray have not 
been met. Therefore, we decided that the Plan does not have to pay for the radiologic examination (x-ray) of 
the ankle (73610) provided on September 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided on July 27, 2023. 
 
You asked the Plan to pay for initial nursing facility care. You say that this service is supported in the records. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for initial nursing facility care provided on July 27, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the dual-energy X-ray absorptiometry (DXA) (77080) provided on 
August 29, 2023. 
 
You asked the Plan to pay for the DXA. You say that the service was billed correctly and should be paid. The 
Plan denied your request. The Plan says that the medical records do not contain a valid diagnosis code from the 
benefits screening categories indicating the reason for the test is postmenopausal female, vertebral fracture, 
hyperparathyroidism, or steroid therapy. 
 
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. We find that the rule used by the Plan to outright deny code 77080 for billing 
issues does not apply to code 77080. The Local Coverage Article (A59040) for this service with jurisdiction 
over the state where this service was performed does not indicate that there are certain diagnosis codes which 
automatically are considered not medically necessary when paired with the service at issue. The Plan has not 
fully substantiated their denial in this case. Therefore, we decided that the Plan has to pay for the dual-energy 
X-ray absorptiometry (DXA) (77080) provided on August 29, 2023.  
 
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 IRF is a venue that will allow the enrollee to 
increase their physical abilities and go home safely. The Plan denied your request. The Plan says the enrollee's 
medical and therapy needs could be met in a skilled nursing facility.  
 
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's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 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. Medically necessary care can be provided in a different 
level of care.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydrocodone-acetamin. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydrocodone-acetamin.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement fluid swing and stance phase control
(L5828), fluid stance extension (L5848), microprocessor control feature (L5856), endoskeletal ankle foot
system (L5973), and stance flexion feature (L5845) for the enrollee.

You asked the Plan to pre-approve this prosthetic equipment. The Plan denied your request. The Plan says the
Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen
and stated that Maximus did not apply the correct criteria. The Plan noted that a new socket has already been
approved. Medicare guidelines say that a replacement prosthesis can be approved if your current prosthesis
cannot be repaired or if repairs are more than 60% cost of replacement.

The document provided does not show either is the case in this enrollee. The notes state the current knee and
foot system can be repaired. A request for repairs for the current prosthetic knee and foot can be reviewed if the
appropriate documentation is submitted.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. Medicare requires specific documentation in the case file to cover repairs or
replacements. Based on the information provided, we decided that there is insufficient information in the record
to determine if Medicare rules for coverage of this prosthetic equipment have been met. Therefore, we decided
that the Plan does not have to pre-approve a replacement fluid swing and stance phase control (L5828), fluid
stance extension (L5848), microprocessor control feature (L5856), endoskeletal ankle foot system (L5973), and
stance flexion feature (L5845) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 15, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for an office visit provided on September 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 02, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for subsequent nursing facility care provided on August 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 
11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are entitled to two cleanings per year. The 
benefit limitation is not clearly identified in the description of benefits and the Plan frequently changes it 
policies leaving confusion for the provider and subscriber. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 5, 2023. Therefore, 
we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 
11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64629, 64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Intracept intraosseous 
basivertebral nerve ablation at L3, L4, L5, and S1, 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64629, 64628).