Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency transport taxi (A0100) provided on April 11, 
2023. 
 
You asked the Plan to pay for non-emergency transport taxi (A0100). You say that you received services in a 
different country for a diagnosis of a possible blood clot in your right leg. You also say you were advised by 
your doctor back home to not fly until you received an ultrasound.  The Plan denied your request. The Plan 
says the taxi ride on April 11, 2023, requested does not meet the requirements for approval. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency transport taxi (A0100). Our 
reviewer says that the service was not medically necessary. Our physician reviewer found you went to the 
emergency room with right leg pain and concerns for a deep vein thrombosis (DVT), which you tested negative 
for. Our physician reviewer also found that you were discharged in a non-emergency taxi, which does not meet 
the criteria for coverage. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency transport taxi (A0100) have not been met. Therefore, we 
decided that the Plan does not have to pay for non-emergency transport taxi (A0100) provided on April 11, 
2023.
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 the enrollee needs this care to enhance 
recovery. The Plan denied your request. The Plan says the enrollee's needs can be safely managed at the current 
facility until they are more stable for transfer to another level of care. 
 
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 the medical record does not indicate that the enrollee requires services that they are 
not currently receiving but would be available at the LTACH facility. 
 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: 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 the LTACH admission is the appropriate 
level of care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the 
LTACH admission.  
 
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 the enrollee is receiving appropriate care in current acute care setting as provided by 
the health Plan. The clinical documentation does not support that LTACH services are medically appropriate 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 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: 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 the enrollee has a lack of mobility and 
needs continuous wound care. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient acute care and is currently unstable for transfer to an LTACH. 
 
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 the enrollee is receiving appropriate care in the current acute care setting as provided 
by Health Plan. Documentation does not support that LTACH services are medically appropriate 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dexamethasone. 
 
You asked the Plan to pre-approve the medication. You say that the request is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve dexamethasone.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited appeal for the denial 
of inpatient acute rehabilitation. The Plan denied your request. The Plan says the request cannot be approved at 
this time.  
 
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 do 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 or occupational therapy, at an 
intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation doesnt 
support that they meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication 
that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours 
a week, under the supervision of a physician with at least three visits weekly to regain or maintain their 
functional status. The enrollee can receive further services 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 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 pre-approve a continuous passive motion (CPM) device. to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve CPM device. You say that this device is medically necessary. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan and the needed equipment can 
be obtained within the Plan network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a continuous passive motion (CPM) device. to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a respiratory assist device, bi-level pressure capability, 
with back-up rate feature (E0471) and supplies (E0562, A7030, A7034, A7035, A7036, A7037, A7038, 
A7039). 
 
You asked the Plan to pre-approve a respiratory assist device and supplies. You say that the requested device is 
medically necessary and will improve the enrollees qualify of life. The Plan denied your request. The Plan says 
the use of a bi-level positive airway pressure device with back-up rate 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 a respiratory assist device and supplies. 
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 bi-level positive airway pressure device (E0471) at issue in this case meets all Medicare criteria for 
medically reasonable and necessary for the enrollee. Provided records in this case document a diagnosis of 
severe obstructive sleep apnea which is an excluded diagnosis for an E0471 per the above cited LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a respiratory assist device and supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a respiratory assist device, bi-level pressure capability, with 
back-up rate feature (E0471) and supplies (E0562, A7030, A7034, A7035, A7036, A7037, A7038, A7039).
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 the LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the LTACH 
admission. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. Given there are offered alternatives, LTACH 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 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: 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 disagree with the denial as the enrollee is weak 
and does not tolerate activities well due to their weakness. The Plan denied your request. The Plan says the 
inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve bock. 
 
You asked the Plan to pre-approve the genicular nerve bock. You say that due to the enrollee's kidney issues 
they are unable to have a total knee arthroplasty. You say that the enrollee has approximately 0 % pain relief on 
the left and 60% pain relief on the right for three to four weeks after their recent bilateral genicular blocks. The 
Plan denied your request. The Plan says the genicular nerve bock 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 the genicular nerve bock. Our reviewer 
says that the genicular nerve bock is not medically necessary. Our physician reviewer found that the genicular 
nerve block is the subject of ongoing clinical trials and is considered an experimental and investigational 
therapy.  
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 genicular nerve bock have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the genicular nerve bock.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313),
electronic connection (E2311), padded footplate cover (K0108) and leg rest assembly (K0108).
You asked the Plan to pre-approve an expandable controller, harness, electronic connection, padded footplate
cover and leg rest assembly The Plan denied your request. The Plan says that the upgraded electronics are not
medically necessary. The Plan also says that the leg rest assembly and footplate cover are not covered.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for expandable
controller, harness and electronic connection. Our Medical Director states that documentation supports that
your upper extremity strength and function appear to be adequate to operate the power options using their own
switches. Our Medical Director found that your condition does not meet criteria for coverage of an expandable
controller, harness and electronic connection.
We looked at this physician's review, the file, and Medicare rules. The requested padded footplate cover does
not serve a medical purpose. The requested leg rest assembly is already included with the approved elevated
leg rest. Based on this information, we decided that Medicare rules for coverage of an expandable controller,
harness, electronic connection, padded footplate cover and leg rest assembly have not been met. Therefore, we
decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313),
electronic connection (E2311), padded footplate cover (K0108) and leg rest assembly (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for procedure code J3490 provided on August 29, 2022.
You submitted this claim for payment. The Plan denied your request. The Plan says Medicare billing criteria
were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan
requested a reopen and noted that the code is incorrect based on Medicare rules. Title XVIII of the Social
Security Act, 1833 (e), prohibits Medicare payment for any claim lacking the necessary documentation to
process the claim. The provider billed J3490 defined as unclassified drugs with no documentation of the
specific drug administered or dosage documented on the claim form. Medicare rules state: All injection claims
must include the specific name of the drug and dosage. The enrollee had Hydromorphone 8mg/ml used to
refill Syncromed Intrathecal Pump. There is/are a more appropriate code(s) for these services. The
medical record indicates Hydromorphone 8mg/ml - 40 ml IT Compounded preservative free intrathecal
med Medicare rules state When submitting a claim for compounded drug(s) for a single agent or a
combination of agents, providers must use code J7999KD. Even though the compound is like or includes a
drug with a specific code, providers must use code J7999, for compounded drug, not otherwise classified, for
reimbursement of the compounded drug. The KD modifier must be appended to indicate the drug will be
administered through a durable medical equipment.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code and when necessary, the
appropriate modifier. In this case, this claim could not be paid as billed due to the incorrect code being reported
for a compounded drug and the omission of the required modifier. Medicare rules for coverage of this claim as
billed have not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490
provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home infusion therapy services (S9328, 62368, 62369, 
G0088, G0068, J7999) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve home infusion therapy. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the enrollee must use network providers to get her 
medical care and services. There are in-network provider(s) within a reasonable distance from the enrollee's 
location that can provide this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home infusion therapy services (S9328, 62368, 62369, G0088, G0068, J7999) to be provided by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 43 fractions of radiation therapy and fractions of image 
guided radiation therapy treatments. 
 
You asked the Plan to pre-approve 43 fractions of radiation therapy and fractions of image guided radiation 
therapy treatments. You say that it is medically necessary. The Plan denied your request. The Plan says the 
requested service is not covered by Medicare or the Health Plan. 
 
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 43 fractions of radiation therapy and 
fractions of image guided radiation therapy treatments. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found intensity-
modulated radiation therapy (IMRT) is appropriate for this enrollee though there is no plausible justification for greater than 20 fractions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 43 fractions of radiation therapy and fractions of image guided radiation therapy 
treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve 43 fractions of 
radiation therapy and fractions of image guided radiation therapy treatments.