Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from December 1, 2022, to December 5, 
2022. 
 You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says  the enrollee no longer had 
skilled nursing facility needs.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from December 1, 2022, to December 5, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aspira brand drainage kit supplies. 
 You asked the Plan to pre-approve Aspira brand drainage kit supplies. You say that the items 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. Medicare rules say that medical supplies are items that, due to their 
therapeutic or diagnostic characteristics, are essential in enabling HHA personnel to conduct home visits or to 
carry out effectively the care the physician has ordered for the treatment or diagnosis of the patient's illness or 
injury. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Aspira brand drainage kit supplies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aspira brand drainage kit supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total disc arthroplasty. 
 
You asked the Plan to pre-approve total disc arthroplasty. 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 follows Medicare rules. Medicare rules say that the lumbar artificial disc replacement (LADR) is a 
surgical procedure on the lumbar spine that involves complete removal of the damaged or diseased lumbar 
intervertebral disc and implantation of an artificial disc. 
 
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 total disc arthroplasty. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the magnetic resonance 
imaging (MRI) shows multilevel degenerative disc disease (DDD) which is a contraindication to disc 
replacement. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of total disc arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve total disc arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor.  
You asked the Plan to pre-approve a FreeStyle Libre 2 sensor. 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. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a FreeStyle Libre 2 sensor have not been met.  Therefore, we decided that the Plan does not have to 
pre-approve a FreeStyle Libre 2 sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (PCD) (E0675) provided on 
July 25, 2022, to August 24, 2022. 
 
You asked the Plan to pay for a PCD. You say that this device is a postoperative requirement from the 
enrollee's physician. The Plan denied your request. The Plan says a PCD billed with E0675 is not eligible for 
reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a PCD have not been met. Therefore, we decided that the Plan does not have to pay for a 
pneumatic compression device (PCD) (E0675) provided on July 25, 2022, to August 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electrolysis epilation (17380). 
 
You asked the Plan to pre-approve the electrolysis epilation. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the electrolysis epilation have been met. There were no medical records submitted in this case file. Therefore, we decided that the Plan does not 
have to pre-approve the electrolysis epilation (17380).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 39 additional speech therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee has previously been authorized to have at least 9 
sessions of speech therapy. Without documentation that treatment has been effective in improving her 
symptoms, additional therapy is not reasonable. The additional therapy services are not an appropriate duration 
and frequency for treatment of the enrollees medical condition and therefore are not medically 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 39 additional speech therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental extraction (D7140). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says dental services from an out-of-network 
provider are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider.  Therefore, we decided that the Plan does not have to pre-approve a dental 
extraction (D7140).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  an Ameriglide Rave 2 stair lift. 
 
You asked the Plan to pre-approve  an Ameriglide Rave 2 stair lift. You say that the items is necessary. The 
Plan denied your request. The Plan says the requested item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured.  Therefore, we 
decided that the Plan does not have to pre-approve  an Ameriglide Rave 2 stair lift.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs further acute rehab as they live 
alone with no support. The Plan denied your request. The Plan says a SNF admission is not medically 
necessary, and the enrollee's needs can be met in another setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found that the enrollee has stabilized medically and is ready for discharge from the 
hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The 
enrollee is medically stable and can receive further rehab services at a lower level of care. Although further 
rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services 
can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental 
medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without 
any acute exacerbations of chronic medical problems. The enrollee's physical function is at or near her baseline 
and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is 
not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services billed to the enrollee for April 22, 2022.
You asked the Plan to pay this claim. The Plan denied your request. The Plan says the records are incomplete to confirm testing was done on the date of service reported. Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and stated that the issue was not medical necessity but that the enrollee had a bone marrow biopsy performed on April 15, 2022. It appears that the testing was performed on this specimen. Generally, the date of service for a clinical laboratory test or the technical component of physician pathology service must be the date the specimen was collected. There is no documentation of cytogenetic testing performed on a specimen collected on April 22, 2022.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine the services were performed on the date of service billed. Therefore, we decided that the Plan does not have to pay for lab services billed to the enrollee for April 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous discectomy at L4-L5 under fluoroscopic 
guidance identified with code 62287. 
 
You asked the Plan to pre-approve percutaneous discectomy at L4-L5 under fluoroscopic guidance. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve percutaneous discectomy at L4-L5 
under fluoroscopic guidance. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has lumbar herniated Disc and 
lumbar degenerative disc with radiculopathy. Percutaneous discectomy is experimental. More research is needed. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous discectomy at L4-L5 under fluoroscopic guidance have not been 
met. Therefore, we decided that the Plan does not have to pre-approve percutaneous discectomy at L4-L5 under 
fluoroscopic guidance identified with code 62287.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lovenox. 
 
You asked the Plan to pre-approve the medication. You say that the services are 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 Lovenox.   
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: 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 enrollee would benefit from a short IRF stay in 
order to return home. The Plan denied your request. The Plan says  the IRF care is not medically necessary, and 
the enrollee's needs can be met at a lower level of care such as a skilled nursing facility, home with home 
health services, or home with outpatient therapy. 
 
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 was admitted for surgical management of a hip fracture after a fall and 
hospital acquired pneumonia. The enrollee's medical problems are stable, and 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 and/or occupational therapy, there is no documented need for intensive 
rehabilitation services 
 
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  the IRF is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and your needs can be met at a lower level 
of care such as 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 you were admitted for lower extremity compartment syndrome and an above the knee 
amputation. Your medical problems are stable, and there are no complex nursing or rehabilitation needs. You 
do 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 and/or 
occupational therapy, there is no documented need for intensive rehabilitation services.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 8, 2022.
You asked the Plan to pay for the limited oral evaluation. You say that it was not discussed with you or checked against your dental plan that the service was not covered. 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 Plan's 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 May 3, 2022. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit (99336) provided on December 21, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that the provider relies on the facility staff to 
obtain the necessary authorizations. The Plan denied your request. The Plan says prior authorization was not 
obtained. 
 
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 provider in this case is not a network provider with the Plan. 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 domiciliary visit (99336) provided on December 21, 2022, by 
an out-of-network (OON) provider.