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 the enrollee needs IRF services as she lives alone 
and is unsafe to discharge home. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees 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. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided on April 11, 2023. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Neither the shipped 
date nor the delivery date matches the billed date of service. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the supplies provided on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crowns - porcelain fused to high noble metal teeth 
#'s 23 and 26 (D2750). 
 
You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says the documentation 
does not meet the clinical criteria for the crowns-porcelain fused to high noble metal. 
 
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. The Plan covers the crowns 
when the services are medically necessary and reasonable.  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 crowns. Our reviewer says that 
these services are not medically necessary. Our physician reviewer found the radiographs provided with the 
documentation were not of diagnostic quality to determine is teeth #'s 23 and 26 have significant breakdown 
due to caries or fractures to require crown restorations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the crowns - porcelain fused to high noble metal teeth #'s 23 and 26 (D2750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a color kit (K0108), hub cap color (K0108), spandex 
fabric domestic cushions (K0108 x2), and extra outer cushion cover (E2619). 
 
You asked the Plan to pre-approve the items. You say that the enrollee would benefit from transition into a 
power wheelchair. The Plan denied your request. The Plan says the color kit and hub cap color are convenience 
items and non-standard upgrades. They do not primarily serve a medical purpose. The Plan says the power 
wheelchair approved (K0861) includes a seat cushion (E2607) and a back cushion (E2620). The Plan also says the spandex fabric cushion (K0108) and replacement cover (E2619) are duplicative and serve the same 
purpose. 
 
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 items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested items including a color kit and hub cap color do not serve a medical purpose and 
therefore are not medically necessary. The extra cushion cover and cushion are duplicate and would be to serve 
a convenience factor and not a medical purpose. The requested accessories 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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a color kit (K0108), hub cap color (K0108), spandex fabric domestic cushions (K0108 x2), and 
extra outer cushion cover (E2619).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Factor V genetic testing (81241, 81400). 
 
You asked the Plan to pre-approve Factor V genetic testing. You say that this testing is vital for the healthcare 
of this patient. The Plan denied your request. The Plan says the enrollee does not meet the limited criteria for 
coverage of these services. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for the Factor V Leiden (FVL) 
variant in the F5 gene is non-covered except for pregnant patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Factor V genetic testing have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Factor V genetic testing (81241, 81400).
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 needs IRF services to give her the best 
opportunity to regain her quality of life. The Plan denied your request. The Plan says the enrollee does not meet 
the requirements 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees 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. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation 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: 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 are unable to walk and require IRF services to
regain your prior level of functioning. The Plan denied your request. The Plan says that the request is not
medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our
Medical Director states that while you were reasonably expected to benefit from physical and occupational
therapy, the documentation does not support that you were in need of an intensive therapy program with
therapy at least 3 hours per day, 5 days per week, with frequent physician oversight and 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service July 16, 
2023 to August 12, 2023. 
 
You asked the Plan to pay for procedure code S9328. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service July 16, 2023 to August 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a brake lever (K0108) and repair or non-routine service 
for durable medical equipment (DME) other than oxygen equipment (K0739 x6). 
 
You asked the Plan to pre-approve the services. You say that you need these services because the brake does 
not work on your old wheelchair. You also say that you need the wheelchair to get around, and this is your 
form of transportation. The Plan denied your request. The Plan says the brake levers should come included with 
each motor and should not have to be covered separately. 
 
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested repairs or replacement to the motor has been authorized and will include new 
brakes. The requested repairs to the brake lever with associated labor costs would be considered duplicate 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve  a brake lever (K0108) and repair or non-routine service for durable medical equipment 
(DME) other than oxygen equipment (K0739 x6).
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 the enrollee's acute kidney injury needs 
daily monitoring and management. You also say the enrollee's needs cannot be adequately cared for in their 
current condition at a skilled nursing facility or any other lower level of care.  The Plan denied your request. 
The Plan says the enrollee does not meet the guidelines for LTACH services.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services ,and these have not been denied.  The medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH facility.  The elements of the coverage 
rules are not satisfied.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for prosthesis additions identified with codes
L5828, L5845, L5848, and L5856.

You asked the Plan to provide coverage for the requested prosthesis additions. The Plan denied your request.
The Plan says the medical records provided do not support the requested equipment. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan
noted that Prosthetist claims you are a K3 ambulator. This is not consistent with available medical history. The
medical records show you are Member and using a cane and a scooter. This is not consistent with K3
ambulation. This cannot be reconciled with a K3 prosthesis, including microprocessor knee (MPK). The
medical records do not show why you require a microprocessor knee, or why another knee would not meet
your needs.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for this type of prosthetic component. 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 with the
medical records and must confirm that Medicare coverage criteria have been met. We looked at the medical
records and Medicare rules. Based on this information, there is insufficient documentation in the medical
records to show you meet the required criteria. Therefore, we decided that the Plan does not have to provide
coverage for prosthesis additions identified with codes L5828, L5845, L5848, and L5856
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) and
supplies for the enrollee.

You asked the Plan to pre-approve a Dexcom G6 CGM and supplies. You say that the enrollee requires a
CGM. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are
covered. Maximus overturned the Plan's denial because of a lack of information. The Plan requested a
reopening and stated that non-preferred brands are not covered. The Plan is correct in this case. The Plan
submitted the 2023 Customer Handbook which indicated their Preferred brands for diabetic supplies. Medicare
rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the
preferred brands or may limit the DME to only those preferred brands and manufacturers. Plans must ensure
that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The
rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under
a plan, including applicable conditions and limitations associated with receipt or use of benefits.

We looked at the file and Medicare rules. According to the EOC and Customer Handbook, the requested brand
is not a preferred brand for a Dexcom G6 CGM and supplies. Therefore, we decided that the Plan does not
have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow orthosis (L3761) provided June 22, 2023. 
 
You asked the Plan to pay for the orthosis. You say that please review the attached documents. The Plan denied 
your request. The Plan says the records do not support the medical necessity for the elbow support brace and 
the providers office denied referring the enrollee to this supplier.  
 
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 pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the elbow orthosis L3761 
at issue in this case meets all Medicare criteria for medically reasonable and necessary for the enrollee. The 
provided medical records in this case do not document any symptoms or signs related to either elbow for which 
an elbow orthosis was recommended as part of a plan 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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the elbow orthosis (L3761) provided June 22, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 1, 2023, to 
August 31, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim was submitted with an invalid type of bill. 
 
The Plan follows Medicare rules. The rules say that home health services must be submitted with a correct type 
of bill. 
 
We reviewed the file and the Medicare rules. We find that the claim was billed with a type of bill of 0323. The 
documentation shows that the type of bill submitted on the claim is incorrect. 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 August 1, 2023, to August 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you really need another FreeStyle Libre 2 with all 
the issues you go through. You also say that your meter stopped working and that is why you need a new one. 
The Plan denied your request. The Plan says there is no documentation of problems with severe or recurrent 
hypoglycemia in your clinical records, and your diabetes is not currently managed with insulin. 
 
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 CGM. Our reviewer says that this 
item is not medically necessary. Our physician reviewer found coverage criteria require insulin use or blood 
glucose sugar in the lower (<) 54 range with recurring symptoms despite adjustments in medications. Although 
you are on a medication that can cause low blood glucose sugar (Amaryl), there is no documentation that you 
are having blood glucose sugar <54. Hence, although you are likely benefiting from a CGM, coverage criteria 
are not met for CGM at this time. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial. The Plan 
denied your request. The Plan says management of power feature using a single joystick rather than their own 
switch is not reasonable and 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 wheelchair accessories. 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 neuropathy and paraplegia. He is able to feed and groom himself. Per 
Medicare necessity guidelines, the enrollee has adequate strength to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a harness (E2313) and an expandable controller (E2377).