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 you need post discharge physical therapy and occupational therapy in an IRF. The Plan denied your request. The Plan says that the IRF services you are requesting do not meet the requirements for approval. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care.
Our Medical Director states that the documentation does not support that the complexity of your nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care, that you required treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program, and that there was a reasonable expectation that you would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. 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 clinical 
documentation shows that the enrollee is ambulating on uneven surfaces outside of home with assistive device 
(>300ft), thus would not be considered home bound or require additional home health physical therapy 
sessions. 
 
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 home health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that Intracept is medically necessary and supported by 
strong science. The Plan denied your request. The Plan says this is 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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found magnetic resonance imaging (MRI) shows spinal stenosis and facet degenerative joint disorder 
and the cause of the enrollee's back pain is unclear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are pertinent for the 
enrollee's full recovery. The Plan denied your request. The Plan says admission to the LTACH is not medically 
necessary. 
 
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 was admitted to the acute care hospital with pneumonia, congestive 
heart failure (CHF) exacerbation, and respiratory failure requiring intubation, percutaneous endoscopic 
gastrostomy (PEG) placement for tube feeds, antibiotics, diuresis, and norepinephrine drip. Recent notes describe the enrollee as still ventilator dependent without recent weaning trials documented and still dependent 
on vasopressors.  
 
The enrollee appears to be currently unstable and requires additional acute care services that can safely be 
administered at the current facility until the enrollee is more stable and appropriate for transfer. 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 as the enrollee is not yet stable enough for transfer 
and as it would not be clinically advantageous.  
 
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 LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. 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 clinical 
documentation shows that the enrollee is completing Activities of Daily Living (ADLs) including meal prep 
independently thus they would not continue to require additional home health occupational therapy sessions. 
 
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 home health 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 recovery is slow and painful and will be quicker with the rehabilitation. The Plan denied your request. The Plan says that your condition does not meet criteria for approval.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care.
Our Medical Director states that the documentation does not support that the complexity of your nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our Medical Director found that your condition does not meet Medicare criteria for IRF 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging 
(92134) provided on November 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmic diagnostic imaging. The Plan denied your request. The Plan says 
this service was rendered by a non-network provider who does not work with the enrollees health plan, and the 
enrollee self-directed for care. The Plan also says the enrollee's primary care provider did not refer for services.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic 
imaging (92134) provided on November 9, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
with a stress test (78452). 
 
You asked the Plan to pre-approve SPECT imaging with a stress test. You say that this service is medically 
necessary as the enrollee has had an abnormal electrocardiogram (ECG) and has many risk factors. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for this service. 
 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 SPECT imaging with a stress test. 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 no cardiac symptoms despite good exercise capacity and 
no ECG abnormality to prevent exercise ECG interpretation. The enrollee would not benefit from adding 
nuclear imaging to the stress ECG. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT imaging with a stress test have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) with a stress test 
(78452).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on January 11, 2023. 
 
You asked the Plan to pay for inpatient hospital services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that the provider billed under inpatient services and the claim 
needs to be billed under observation care instead. 
 
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. Prior to January 01, 2023, observation care provided by a doctor in a hospital 
had very specific observation-only current procedural terminology codes (CPT) that needed to be billed. 
However, as of January 1, 2023, the codes for observation and inpatient hospital physician services have 
merged. The rule is no longer in effect. Therefore, we decided that the Plan has to pay for inpatient hospital 
services provided on January 11, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for pontic - porcelain fused to noble metal (D6242) Tooth 
#7 and retainer crown - porcelain fused to noble metal (D6752) Tooth #6 and 8 provided on September 22, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that you do not understand why part of the 
services you received are denied and why you are paying so much when you have $0 and 50% deductibles. The 
Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 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. Enrollees must pay 50% 
coinsurance for covered out-of-network dental services and may be billed by the out-of-network provider for 
any charged amount greater than the payment made by the Plan. This benefit includes the requested pontic - 
porcelain fused to noble metal (D6242) and retainer crown - porcelain fused to noble metal (D6752) but is 
limited to one procedure code every five calendar years. 
 
The allowed amounts of the covered dental services total $1,145, resulting in a coinsurance amount of $572.50 
and a Plan payment of $572.50. 
 
You may also be asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D6752 Tooth #6 on September 22, 2022; therefore, this benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for retainer crown - porcelain fused to 
noble metal (D6752) Tooth #8 provided on September 22, 2022. 
 
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 pay more for pontic - porcelain fused to noble metal (D6242) Tooth #7 
and retainer crown - porcelain fused to noble metal (D6752) Tooth #6 provided on September 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 2, 2022, to 
January 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that due to the difficulties 
experienced in processing the NOAs, we are requesting UHC reprocess and pay the claim in full. The Plan 
denied your request. The Plan says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 2, 2022, to 
January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging 
(92134) provided on September 13, 2022, by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the scanning computerized ophthalmic diagnostic imaging. The Plan denied your 
request. The Plan says this service was rendered by a non-network provider who does not work with the 
enrollees health plan, and the enrollee self-directed for care. The Plan also says the enrollee's primary care 
provider did not refer for services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic 
imaging (92134) provided on September 13, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and supplies provided 
on November 18, 2022. 
 
You asked the Plan to pay for the continuous glucose monitor (CGM) and supplies. The Plan denied your 
request. The Plan says the enrollee does not require insulin three or more times daily. 
 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor (CGM) and supplies have not been met. Therefore, we decided that the Plan does 
not have to pay for a continuous glucose monitor (CGM) and supplies provided on November 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma test provided on November 8, 
2022. 
 
You asked the Plan to pay for the DecisionDx-Melanoma test. You say that this test was ordered by the 
enrollee's treating physician to inform treatment decisions. The Plan denied your request. The Plan says the 
enrollee's records do not show a stage Ib lesion, a documented concern about the adequacy of microstaging, or 
a presumed risk for a positive sentinel lymph node biopsy greater than 5% 
 
The Plan follows Medicare rules. Medicare rules say that this test is covered when the criteria in the rules 
section are met. 
 
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 the DecisionDx-Melanoma test. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found per the National 
Comprehensive Cancer Network (NCCN) Guidelines, despite commercially available gene expression profiling 
(GEP tests), such as DecisionDx Melanoma, being marketed to risk stratify cutaneous melanomas, current GEP 
platforms do not provide clinically actionable prognostic information when combined or compared with known 
clinicopathologic factors (eg, sex, age, primary tumor location, thickness, ulceration, mitotic rate, 
lymphovascular invasion, microsatellites, and/or SLNB status) or multivariable nomograms/risk calculators. 
Furthermore, the clinical utility of these tests to inform treatment recommendations and predict patient 
outcomes has not been established. The service was not reasonable or 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 DecisionDx-Melanoma test have not been met. Therefore, we decided that 
the Plan does not have to pay for the DecisionDx-Melanoma test provided on November 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and progressive lenses (V2781) 
purchased on November 21, 2022. 
 
You asked the Plan to pay for the frames and progressive lenses. You say that you went to the provider, were 
told they were out-of-network, and advised to submit your bill and explanation to the Plan. You also say that 
you contacted the Plan and were told to send the receipt to the Plan, and it would be processed. The Plan denied 
your request. The Plan says it was verified that you do not have non-Medicare covered vision benefits with the 
Plan. The Plan also says that you are responsible for the full cost of the non-covered services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. The record shows 
that when you contacted the Plan prior to receiving this eyewear, you were correctly advised that you did not 
have coverage for eyeglasses, and you were offered the Optional Supplemental Benefit to add on. The record 
shows that no misinformation was provided by the Plan. Therefore, we decided that the Plan does not have to 
pay for the frames (V2020) and progressive lenses (V2781) purchased on November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and accessories. You say that this is 
medically necessary. The Plan denied your request. The Plan says the enrollee has no qualifying diagnosis for a 
group 3 power wheelchair. 
   
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 standard power wheelchair and accessories.