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

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth 
number 31. 
 
You asked the Plan to pre-approve the dental services. You say that you require these services in order to chew 
properly. 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 items or services was exhausted on date of service July 31, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) 
for tooth number 31.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation has been recommended by 
your treating physician. The Plan denied your request. The Plan says that you do not meet IRF admission 
criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the Plan erred in its denial of IRF admission. Per Medicare Benefit Policy Manual Ch 1, 110, and 42 
CFR 412.622, the medical record overall significantly complies with the various documentation requirements 
for IRF admission.  Indeed, your condition is complex and fragile, and there is every reason to expect that you 
will participate in and benefit from IRF-level services to include at minimum physical therapy, occupational 
therapy, physician oversight of polypharmacy, and case manager coordination of any additional services that 
might be needed to make a sustainable return home in the face of your ongoing oncological challenges, as well 
as avoid preventable readmission to the acute hospital. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. You asked the Plan to pre-approve Vabysmo. 
You say that you are uncomfortable using Byooviz and do not stock Byooviz in your office. The Plan denied your request. The Plan says there is no record that shows the enrollee has tried the preferred drug, Byooviz, and 
it has not worked or that the enrollee has medical reasons that prevent them from using it.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Vabysmo. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that the provided records do not 
indicate the enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate 
that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step one 
alternative. The elements of the coverage criteria 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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
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 prefer to admit to acute rehabilitation because 
you were independent before your hospitalization and you want to return to being independent. The Plan 
denied your request. The Plan says the IRF services requested 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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. You continue to have a need for skilled therapy however, the documentation 
doesnt support that you meet criteria for admission to an acute inpatient rehabilitation facility. You 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: 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 will clearly benefit from acute 
rehabilitation to optimize their level of functioning prior to returning home. The Plan denied your request. The 
Plan says the IRF services requested 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 complexity of the enrollees 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 therapy 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. 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox 200-unit injection. 
 You asked the Plan to pre-approve Botox injection. You say that you are asking for authorization of the Botox 
medication as the Interstim device is no longer effective. The fact that the Interstim device was approved would 
indicate that previous medication trials were not effective. The Plan denied your request. The Plan says the 
criteria have not been met and the provider has not demonstrated that it is medically necessary to make an 
exception. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Botox injection. Our reviewer says that 
the records do not show that step therapy criteria has not been met in this case. Our physician reviewer found 
the enrollee has a diagnosis of urgency of urination with urge incontinence. An Interstim device was previously 
placed. The case file does not contain documentation of a trial of 1 urinary anticholinergic drug and Myrbetriq. 
The available documentation does not support that a trial of 1 urinary anticholinergic drug and Myrbetriq 
would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox 200-unit injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient stay provided from April 28, 2023, to May 8, 
2023. 
 
You asked the Plan to pay for the inpatient stay. You say that you would like the whole inpatient stay from 
April 4, 2023, to May 8, 2023, to be approved. The Plan denied your request. The Plan says as of April 28, 
2023, you were appropriate to discharge to a lower level of care. 
 
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 the inpatient stay. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found you presented with an infected left foot and seizures, and were treated in the hospital with 
wound care and antibiotics. The documentation from April 27, 2023, describes you with stable hemoglobin, 
afebrile, no leukocytosis, tolerating treatment without ongoing complication, no plans for additional surgery, 
and hemodynamically stable with you being alert and having the ability to communicate. Our reviewer found 
that the documentation described you as appropriate for a lower level of care. Our physician reviewer found 
that therefore, it was not expected that you would have required additional two-midnight or greater extension of 
inpatient services or have an adverse event if you were transferred to a lower level of care at that 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 inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient stay provided from April 28, 2023, to May 8, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional ambulance mileage (non-covered) (A0888) 
provided on May 9, 2023. 
 You asked the Plan to pay for non-covered ambulance mileage. You say that this transportation was medically 
necessary, and you do not understand why part of this claim is not being paid. The Plan denied your request. 
The Plan says this additional mileage is not covered by Medicare or your plan. 
 
The Plan must follow Medicare rules. Medicare rules say that miles beyond the closest available facility cannot 
be billed to Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of non-covered ambulance mileage have not been met. Specifically, these miles account for excess 
distance between the destination facility and the facility which was closest to the point of origin which could 
have accepted you. These miles are not covered by Medicare. Therefore, we decided that the Plan does not 
have to pay for additional ambulance mileage (non-covered) (A0888) provided on May 9, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 all criteria. The Plan denied your 
request. The Plan says that the enrollee does not meet all requirements for 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the Plan erred in its denial of IRF admission. Per Medicare Benefit Policy Manual Ch 1, 110, and 42 
CFR 412.622, the medical record overall significantly complies with the various documentation requirements 
for IRF admission. Indeed, this enrollees condition is complex and fragile, and there is every reason to expect 
that he will participate in and benefit from services to include at minimum physical therapy, occupational 
therapy, physician oversight of polypharmacy, and case manager coordination of any additional services that 
might be needed to make a sustainable return home, as well as avoid preventable readmission to the acute 
hospital. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services billed to the enrollee for February 5, 2021,
under code 81479-GZ.
You asked the Plan to pay for these services. 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
insufficient information in the case file. The Plan requested a reopen and provided additional information. The
Plan demonstrated that this claim was billed using modifier GZ, which per Medicare regulations is indicative of
services whose coverage is to be automatically denied. As a result, the Plan denied payment for the claim.
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. In this case, this claim was
billed with a modifier that requires automatic denial for Medicare claims. Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for medical services
billed to the enrollee for February 5, 2021, under code 81479-GZ.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97116 and 97530 billed for date of service 
June 10, 2023. 
 
You asked the Plan to pay for procedure codes 97116 and 97530. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says these codes are not 
supported for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97116 is therapeutic procedure, 1 or more areas, each 15 
minutes; gait training (includes stair climbing). The CPT Code Manual definition of code 97530 is therapeutic 
activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), 
each 15 minutes. 
 
We asked our coder 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 procedure codes 97116 and 97530. Our reviewer says that 
these codes are not supported in the medical record. Our reviewer found that the documentation does not 
indicate the specific number of minutes providing the services described by codes 97116 and 97530. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 97116 and 97530 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 97116 and 97530 billed for date of service June 10, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99344 billed for date of service January 17, 
2023. 
 
You asked the Plan to pay for procedure code 99344. You say that this service was necessary and was reported 
appropriately. The Plan denied your request. The Plan says this service was not reported with an appropriate 
procedure code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99344 is home visit for the evaluation and management 
of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive 
examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. 
 
We find that CPT code 99344 is not supported in the medical record. Specifically, the enrollee's claims history 
indicates that they have received care from this provider in previous appointments. The services at issue would 
not be considered a new patient visit and would be more accurately reported with a different code. Based on 
this information, we decided that Medicare rules for coverage of procedure code 99344 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99344 billed for date of service 
January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromodulation interferential non-surgical device (97139), 
injection (96372), office visit (99214), levocarnitine (J1955), vitamins (J3490 x 3), and self-care/home 
management training (97535) provided on May 22, 2023.  
 
You asked the Plan to pay for the outpatient services. You say that this was medically necessary for the 
enrollee. The Plan denied your request. The Plan says electrostimulation for the treatment of neuropathies 
caused by systemic disease is not reasonable and necessary. The Plan also says the subcutaneous injection of 
the levocarnitine, lidocaine, and vitamins are not covered either. 
 
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 outpatient services. Our reviewer says 
that the outpatient services were not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation indicates that the enrollee reported uncontrolled blood glucose. 
The reviewer found that first line treatment for diabetic neuropathy is strict glucose control via lifestyle 
changes and medications. However, it was not clear that this was fully exhausted. Also, the provided 
documentation did not clearly show evidence of vitamin deficiencies or an inability to take them orally (food, 
supplements) to justify injectable vitamins. Also, neuromodulation device use has not been shown in high 
quality studies to be helpful for systemic neuropathy such as in this case. The self-care training should be part 
of the office visit itself and is not justified here. Therefore, without sufficient support made for these services 
will be considered 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 outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for neuromodulation interferential non-surgical device (97139), injection (96372), office 
visit (99214), levocarnitine (J1955), vitamins (J3490 x 3), and self-care/home management training (97535) 
provided on May 22, 2023.