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

 
We decided that the Plan does not have to pre-approve 13 home health physical therapy visits and 5 home 
health skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not require additional skilled nursing or rehabilitation services to effectively provide treatment, care, 
and/or services in order to improve the enrollees condition, perform a maintenance program to maintain the 
enrollees condition and/or prevent deterioration. The enrollee has been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 13 home health physical therapy visits and 5 home health skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture (D5214) for the enrollee.

You asked the Plan to pre-approve a lower partial denture. You say that you are requesting a reconsideration of
the Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item or service has
already been exhausted. Maximus overturned the Plan's denial based on a lack of information. The Plan
requested a reopening and provided documentation showing a lower partial denture was already provided by
the Plan.

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, October 18, 2022. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5214) for the
enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre kit 2 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre kit 2 sensor. You say that the medical records provided 
support the need for the requested CGM. The Plan denied your request. The Plan says a CGM is covered under 
Medicare only if an enrollee with diabetes is on insulin or has documentation of very low blood sugars that has 
occurred several times.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle Libre kit 2 sensor. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found coverage criteria require 
insulin use or low blood glucose sugar. We are not told of low blood glucose sugar although the enrollee is on a 
medication that can cause this. The enrollee is not on insulin though this was an option discussed. Coverage 
criteria has not been met. 
 
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 FreeStyle Libre kit 2 sensor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a FreeStyle Libre kit 2 sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96375 billed for date of service June 16, 
2023. 
 
You asked the Plan to pay for procedure code 96375. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says the provided medical records do not support the service 
billed. 
 
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 96375 is: Therapeutic, prophylactic, or diagnostic 
injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List 
separately in addition to code for primary procedure). 
 
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 procedure code 96375. Our reviewer says that procedure 
code 96375 does not meet criteria for payment. Our reviewer found that the procedure report does not include 
documentation of a therapeutic, prophylactic or diagnostic injection, with drug specification. The procedure at 
issue was not found in medical record and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 96375 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 96375 billed for date of service June 16, 2023.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary, but skilled therapies at a 
skilled nursing facility (SNF) may be approved upon request.  
 
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 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. Medically necessary 
care can be provided in a different level of care. 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: 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 you need this level of care. The Plan 
denied your request. The Plan says you do not meet criteria for admission to the long term acute care facility. 
 
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 you were found to have infected pacemaker leads requiring an implantable 
cardioverter defibrillator. You then had an acute worsening of your ejection fraction (to 15%), delirium, 
bilateral infiltrates and effusions. You have since improved significantly and will have a pacemaker replaced at 
a later date after finishing intravenous antibiotics.  Your wound care is non-complex and it would appear that your needs can be met at a lower 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Spinal Simplicity interspinous-interlaminar fusion 
device (Minuteman device). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Spinal Simplicity interspinous-interlaminar fusion device (Minuteman device).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 81003) rendered on 
March 2, 2023. 
 
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 the records do not support the services billed. 
 
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 81003 is "Urinalysis, by dip stick or tablet reagent for 
bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any 
number of these constituents; automated, without microscopy." 
 
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 the laboratory report does not 
include documentation of urinalysis, by dip stick or tablet reagent. There was no physician order for the 
procedure found in the medical records. The procedure cannot be verified. 
 
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 laboratory services (procedure code 81003) rendered on March 2, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for therapeutic facet joint procedures. 
 
You asked the Plan to pay for therapeutic facet joint procedures. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says that they are not reasonable 
and necessary under Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 therapeutic facet joint procedures. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found this would be the second set of injections prior to radiofrequency ablation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapeutic facet joint procedures have been met. Therefore, we decided that the 
Plan has to pay for therapeutic facet joint procedures.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85045 billed for date of service April 19, 
2023. 
 
You asked the Plan to pay for procedure code 85045. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says the documentation provided does not show that this 
service was requested by the enrollee's treating physician. 
 
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 if Medicare rules for coverage of procedure code 85045 have been met. 
Specifically, the laboratory order provided does not list the test described by procedure code 85045 as a 
requested service. In addition, there are no physician notes or medical records to support that this service was 
intended. Therefore, we decided that the Plan does not have to pay for procedure code 85045 billed for date of 
service April 19, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF services as the enrollee's 
needs cannot be met a lower level of care. The Plan denied your request. The Plan says that the enrollee does 
not meet the criteria for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the enrollee's nursing, medical, and rehabilitation needs would be expected to require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Clinical documentation 
shows that the enrollee's past level of function was independent with mobility and self-care tasks, currently 
requiring minimal assist with mobility tasks and minimal to maximum assist with self-care tasks, thus the 
enrollee requires ongoing physical and occupational therapy. Evaluating therapists documentation show that 
the enrollee has good participation and is expected to participate in an intensive rehabilitation regimen in an 
IRF setting. The enrollee would be expected to significantly benefit from an intensive rehabilitation program. 
IRF criteria has been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7. 
 
You asked the Plan to pre-approve the Dexcom G7. You say that the medical records provided support the need 
for the requested CGM. The Plan denied your request. The Plan says a CGM is covered under Medicare only if 
an enrollee with diabetes is on insulin or has documentation of very low blood sugars that has occurred several 
times.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the Dexcom G7. Our reviewer says that 
this item is not medically necessary. Our physician reviewer found coverage criteria require insulin use or low 
blood glucose sugar. The enrollee is not on medications now that cause low blood glucose sugar. We are not 
told of any low blood glucose sugar, or if there is a reason why fingerstick meters would not suffice. Although 
the CGM may help the enrollee, coverage criteria have not been met. 
 
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 Dexcom G7 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Dexcom G7.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Magnetic resonance imaging (MRI) 
provided on April 11, 2023. 
 
You asked the Plan to waive the copayment for the Magnetic resonance imaging (MRI). You say that you 
should not be responsible for a 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 you must pay a $150 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for the Magnetic resonance imaging (MRI). This item/service 
falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 copayment for the Magnetic resonance imaging (MRI) provided on April 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostatic artery embolization. 
 
You asked the Plan to pre-approve prostatic artery embolization. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
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 prostatic artery embolization. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that prostatic arterial embolization (PAE) is considered an experimental technique to 
treat symptomatic benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-
term safety and efficacy. The most recent American Urological Association (AUA) guidelines do not recommend this procedure outside of a clinical trial setting due to the heterogeneity in the available literature 
and safety concerns regarding radiation exposure, postembolization syndrome, vascular access, technical 
feasibility and higher clinical failure rate compared with more traditional methods of treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostatic artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve prostatic artery embolization.