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 IRF services are medically necessary. The Plan 
denied your request. The Plan says based on the available information, admission to an IRF is not reasonable 
and necessary.  
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that 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. Our physician reviewer also found that 
there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the IRF criteria. The Plan denied 
your request. The Plan says an IRF admission is not medically necessary.  
 
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 enrollees 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on August 19, 
2023. 
 
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for emergency care. 
 
You have been asked to pay a $50 copayment for emergency care. This item/service falls within the emergency 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on 
August 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 heavy duty power wheelchair with multiple 
power options (tilt/recline, legrests) and accessories. 
 
You asked the Plan to pre-approve a Group 3 heavy duty power wheelchair with multiple power options. You 
say that you are unable to move like you want and need to. You say that this PWC will keep you from getting 
bed sores. You also say that you need to be able to recline. The Plan denied your request. The Plan says there is 
no medical need for the requested power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 heavy duty power wheelchair with 
multiple power options may be covered if the coverage criteria 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 pre-approve a Group 3 heavy duty power wheelchair 
with multiple power options. Our reviewer says that the requested Group 3 heavy duty power wheelchair with 
multiple power options is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate that the enrollee has high risk for skin breakdown, uses a catheter intermittently, has spasticity 
or requires an alternative means of managing power drive. Therefore, the reviewer found that the requested 
Group 3 heavy duty power wheelchair with multiple power options is 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 a Group 3 heavy duty power wheelchair with multiple power options have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 heavy duty power 
wheelchair with multiple power options (tilt/recline, legrests) and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear implant for the right ear. 
 
You asked the Plan to pre-approve a cochlear implant. You say that the enrollee has failed a hearing aid trial 
for the right ear. You also say that the enrollee is a candidate for a cochlear implant. The Plan denied your request. The Plan says the documentation does not show that the enrollee has a diagnosis of bilateral moderate 
to profound sensorineural hearing impairment. The Plan also says that this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that cochlear implantation may be covered for treatment 
of bilateral hearing loss in individuals who demonstrate limited benefit from amplification. 
 
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 cochlear implant. Our reviewer says 
that the requested cochlear implant is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has unilateral sensorineural hearing impairment. The reviewer found that the noted 
condition is not one for which coverage is available under the rules for the requested service. Therefore, the 
reviewer found that the requested cochlear implant is 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 a cochlear implant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a cochlear implant for the right ear.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on August 
05, 2023, to August 07, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 
copayment for inpatient hospital care. 
 
You have been asked to pay a $395 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient 
hospital care provided on August 05, 2023, to August 07, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF services are medically necessary. The Plan 
denied your request. The Plan says the IRF requirements are not met.  
 
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's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on September 28, 2023. 
 
You asked the Plan to pay for the medication. 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 pay for the self-administered drugs 
provided on September 28, 2023.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a knee nerve block provided on August 07, 
2023. 
 
You asked the Plan to waive the copayment for a knee nerve block. You say that this is not a surgery, just an 
injection! It is too high of a cost for this simple service. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $350 copayment for a knee nerve block. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a knee nerve block provided on 
August 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service June 21, 
2023. 
 
You asked the Plan to pay for procedure code 99140. You say that 99140 should be paid as billed because it is 
supported in the documentation. The Plan denied your request. The Plan says procedure code 99140 is 
considered bundled and not separately payable.  
 
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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair (K0823) and 
group 24 non-sealed lead acid battery (E2362). 
 
You asked the Plan to pre-approve a Group 2 standard power wheelchair and group 24 non-sealed lead acid 
battery. You say that you currently walk with a walker, but it is extremely limiting on you for the type of 
activities with your family and church that you would like to be a part of. You also say that you would like this 
denial to be reconsidered so you can have a better quality of life. The Plan denied your request. The Plan says 
the requested service is not medically necessary because you can meet mobility needs with a walker. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   
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 Group 2 standard power wheelchair 
and group 24 non-sealed lead acid battery. Our reviewer says that the criteria for coverage have not been met. 
Our physician reviewer found you use a walker in your home to complete self-care. Our reviewer also found 
that you do not require a powered wheelchair to complete self-care in the home. 
 
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 Group 2 standard power wheelchair and group 24 non-sealed lead acid battery 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 standard power 
wheelchair (K0823) and group 24 non-sealed lead acid battery (E2362).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair of complex retinal detachment provided on September 
26, 2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for repair of complex retinal detachment with an out-of-network provider. You say 
that the service should be covered. The Plan denied your request. The Plan says no medical necessity for an 
out-of-network provider has been documented. The service is available in-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 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 repair of complex retinal detachment provided on 
September 26, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional acupuncture visits. 
 
You asked the Plan to pre-approve additional acupuncture visits. You say that you are requesting 12 additional 
acupuncture visits for the enrollee in order to sustain and enhance the pain relief and mobility improvements 
already achieved during the cold winter months. The Plan denied your request. The Plan says the benefits have been exhausted. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the record shows the enrollee will have used all 20 
visits as of November 15, 2023. Therefore, we decided that the Plan does not have to pre-approve additional 
acupuncture visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary, but skilled therapies at a 
skilled nursing facility may be approved upon request.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay for ambulance transport provided on December 19, 2022.

You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for
medical necessity. The Plan requested a reopen and noted the issue was not medical necessity but deficient
information on the claim. The claim did not include the required dual diagnosis codes for this transport.

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, the claim was not submitted with the required diagnosis codes. Based on
this information, we decided that Medicare rules for payment of this transport have not been met. Therefore,
we decided that the Plan does not have to pay for ambulance transport provided to the enrollee on December
19, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided to the enrollee on April 27,
2023.

You asked the Plan to pay for the Guardant360 testing. You say that the test was medically necessary. The Plan
denied your request. The Plan says the claim for this molecular pathology testing did not include the required
unique identifier. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that
Maximus did not apply the correct criteria.

The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue,
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the
coverage status is listed in the DEXTM Diagnostics Exchange.

We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier
was reported. The Z-code on the claim is not listed as valid for the CPT code billed. Based on this information,
we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we
decided that the Plan does not have to pay for the Guardant360 testing provided to the enrollee on April 27,