Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you recently had a heart attack and required 
cardiopulmonary resuscitation which did damage to your lungs. The Plan denied your request. The Plan says an 
IRF admission is not medically necessary, and your needs can be met in other settings.  
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan with concurrently 
acquired computed tomography (CT) of the whole body.  
 
You asked the Plan to pre-approve the PET/CT scan. You say that the PET scan is medically necessary. The 
Plan denied your request. The Plan says that they need the doctors notes that give the findings of the testing 
that has already been approved.  
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 pre-approve the PET/CT scan. Our reviewer says 
that the PET/CT scan is medically necessary. Our physician reviewer found the enlarged mediastinal lymph 
nodes along with a lung nodule and a history of smoking is strongly suspicious for lung cancer. The PET scan 
will help to determine whether the enrollee is an appropriate candidate for an invasive diagnostic biopsy 
procedure and the optimal location where the biopsy should be performed. 
 
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 PET/CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) scan with concurrently acquired computed tomography (CT) of 
the whole body.   
 
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 pre-approve retainer crown (D6750). 
 
You asked the Plan to pre-approve the dental services. You say that this should be 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve retainer crown (D6750).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the molecular genetics; interphase in Situ hybridization, 
analyse 100-300 cells (88275) and molecular genetics; DNA probe, each (e.g., FISH) (88271). 
 
You asked the Plan to pre-approve the laboratory services. You say that it is imperative that the enrollee have 
insurance approval to undergo flow cytometry and FISH testing as needed at the time of the bone marrow 
biopsy. If not, the enrollee may incur the need for a second procedure to obtain the studies.  The Plan denied 
your request. The Plan says the documentation does not meet the criteria. 
 
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 laboratory services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in the records for the enrollee, the above criteria is not met for the FISH testing. In 
fact, the pathology showed normocellular bone marrow without dysplasia or increased blasts, no abnormal 
lymphocyte or plasma cell population. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the molecular genetics; interphase in Situ hybridization, analyse 100-300 cells 
(88275) and molecular genetics; DNA probe, each (e.g., FISH) (88271).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient stay post-surgery for a total shoulder 
arthroplasty (23472). 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay is medically necessary. The 
Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record does not show that the admitting physician reasonably would expect 
the enrollee's necessary hospital care would span two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient stay post-surgery for a total shoulder arthroplasty (23472).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair multiple power options and 
accessories, including upgraded electronics, mobile forearm support, and contoured hand pad. 
 
You asked the Plan to pre-approve upgraded electronics, mobile forearm support, and contoured hand pad. You 
say that you would like to appeal this denial. The Plan denied your request. The Plan says payment for an arm 
pad is included in the approved power tilt and recline feature. The Plan says that the code used for the arm 
trough does not match the item requested and therefore cannot be covered. The Plan also says the requested 
upgraded electronics exceeds the enrollee's need.   

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 upgraded electronics, mobile forearm 
support, and contoured hand pad. Our reviewer says that the requested upgraded electronics, mobile forearm 
support, and contoured hand pad are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation supports that the enrollee has adequate upper body 
strength to manage multiple power drive controls. The reviewer also found that the requested molded arm rest 
and contoured hand rest exceed standard issue items. The documentation does not support that these items are 
medically needed. Therefore, the reviewer found that the requested features are not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upgraded electronics, mobile forearm support, and contoured hand pad have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair 
multiple power options and accessories, including upgraded electronics, mobile forearm support, and contoured 
hand pad.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot hold oxygen in your body due to a 
collapsed lung. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and 
your needs can be met in other settings.  
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that you need additional therapy for your 
left shoulder. The Plan denied your request. The Plan says 7 additional physical therapy visits are 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 physical therapy visits. 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 you have chronic pain and impaired range of motion. 
While you have a stable shoulder and can continue with a home exercise program the therapist has not 
provided a rationale for continued therapy based on their response to previous sessions. Therefore, continued 
input from a skilled therapist 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 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 7 additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from April 24, 2022, to May 10, 2022.
You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional documentation. The Plan provided documentation to show the Plans audit initially reduced the billed amount for two separate reasons: 1) Disallowed $51,703.00 in charges for bundling (Denial reason G) 2) Disallowed $4278.00 in charges for three days of intensive care level of care (Denial reason O)
The Plan noted reducing the charges on the claim to $555,457.23 reduces the PPS allowable for DRG 956 from $70,846.25 to $62,471.50, therefore this was the reason for the $7666.28 overpayment when taking the 1% sequestration reduction into account.
The Plan further stated in the reopen it was decided to overturn the reduction for the three days of intensive care but upholding the reduction for bundling, now making a new PPS allowable amount of $63,111.49.
The Plan provided the Pricing Sheet, IB summary and list of approved charges which were considered during the appeal review. The Plan reviewed these documents and made the determination to uphold the original denial based on the Medicare billing guidelines.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case this claim was not paid as original billed due to issues with separately reported bundled codes. The Plan noted that overturned the denial for three days of intensive care. Medicare rules for coverage of this claim as original billed were not met. Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee from April 24, 2022, to May 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for IRF admission, and you 
live home alone and cannot move around safely. The Plan denied your request. The Plan says the records do 
not show that the enrollee needs an intensive team for their care. The services they need can be provided safely 
in other settings, for example, 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for a hip fracture after a fall. Medical problems are stable. There are no complex nursing 
or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
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 this 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic for teeth #8, #9, #10 and #11 (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted on teeth 
#5, #6, #7 and #12. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve pontic for teeth #8, #9, #10 and #11 (D6245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM. 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that your provider requested a CGM because 
you cannot use the common method of testing your blood sugar. The Plan denied your request. The Plan says 
you do not meet the Medicare criteria for a CGM. 
  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 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic CGM.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve clinical crown lengthening services (D4249). 
 
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 the services denied correctly as they do 
not fall within your dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
clinical crown lengthening services (D4249).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve alignable system (L5910), shock reducing pylon (L5988), and 
volume management system (L5781). 
 
You asked the Plan to pre-approve alignable system, shock reducing pylon, and volume management system. 
You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says that the requested 
items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that prostheses and accessories are covered for certain 
indications. 
 
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 alignable system, shock reducing pylon, 
and volume management system. Our reviewer says that the documentation supports that the requested items 
are medically reasonable and necessary. Our physician reviewer found the enrollee has a transtibial amputation 
and requires a prosthesis for mobility and accomplishing daily activities. His current prosthetic socket is no 
longer fitting due to changes in the volume of his residual limb, and he requires a new prosthesis. The alignable 
system is required to allow for the proper positioning of the socket relative to the prosthetic foot and ankle. The 
shock reducing plyon and volume management system for the patients prosthetic socket are also necessary to 
reduce movement within the socket as well as stress and loading of the patients residual limb. The patient is 
noted to have difficulty with the fit of his residual limb within the socket due to hyperhidrosis and volume 
fluctuation. 
Therefore, the enrollee meets criteria for the requested alignable system (L5910), shock reducing pylon 
(L5988) and volume management system (L5781). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of alignable system, shock reducing pylon, and volume management system have 
been met. Therefore, we decided that the Plan has to pre-approve alignable system (L5910), shock reducing 
pylon (L5988), and volume management system (L5781).  
 
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 replacement insulin pump. 
 
You asked the Plan to pre-approve insulin pump. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the enrollee has a functional insulin pump and an upgraded pump with 
Bluetooth is mainly for the convenience of the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of durable medical equipment is not 
covered during the reasonable useful lifetime of the equipment.  
 
We looked at the file and Medicare rules. The enrollees current insulin pump was obtained on July 20, 2021; 
therefore, it is still within its reasonable useful lifetime. Based on this information, we decided that Medicare 
rules for coverage of a replacement insulin pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a replacement insulin pump.