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 you need to be assessed both medically and 
functionally regarding your functional capacity to determine whether you can benefit from a rehabilitation level 
of care offered by mentioned facility. The Plan denied your request. The Plan says you do not meet the criteria 
for admission to an IRF.  
 
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 you continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement however, the documentation doesnt support that you would 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 rehab services 15 hours a week, under the supervision of a 
physician with at least 3 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 glucose monitor. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. In this case, there are no medical records to show that the enrollee 
has diabetes, uses insulin or has a history of problematic hypoglycemia, or has had an in-person visit to 
evaluate their diabetes control and to determine whether the criteria for coverage have been met. Based on this 
information, we decided that Medicare rules for coverage of the requested services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
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 requested facility is the only one that 
has all the equipment needed to help the enrollee get better. 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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility.  
 
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 Plan's denial. The Plan denied 
your request. The Plan says the requested 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 the enrollee required minimal assistance for transfers and ambulation. The enrollee 
required maximum assistance with toileting. Rehabilitation following uncomplicated hip replacement does not 
require intensive rehabilitation services per evidence based and clinical practice standards. Therefore, the 
enrollee does not meet criteria for the requested admission. 
 
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 the continuation of inpatient mental health care from 
July 4, 2023, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that it was difficult to assess the 
enrollee adequately while they were experiencing an altered mental status due to the elevated ammonia. You 
also say that you would like the stay from July 4, 2023, to July 11, 2023, to be approved.  The Plan denied your request. The Plan says the request for continued stay at the psychiatric inpatient hospitalization level of care is 
not approved.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found the admission of this enrollee does not meet the criteria for July 4, 2023, forward as 
the enrollee was not shown to be a danger to themselves or others, delusions, auditory or visual hallucinations 
noted. The enrollee was cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of inpatient mental health care from July 4, 2023, forward.
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 the medical records support the need for the IRF 
admission. The Plan denied your request. The Plan says based on Medicare guidelines and the information we 
have about the enrollee's condition they do not meet all of the requirements 
 
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 has impaired capacity to respond to therapy. Per clinical and evidence 
based standards as the enrollee cannot participate fully in intensive rehabilitation secondary to her weight 
bearing status and there is no evidence she will respond to more intensive therapy as she has not responded 
much to current therapy. The enrollee does not require frequent physiatry oversight. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified periodontal procedure (D4999) provided on 
October 25, 2022. 
 
You asked the Plan to pay for unspecified periodontal procedure. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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 pay for 
unspecified periodontal procedure (D4999) provided on October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), an electronic 
connection (E2311), and a harness upgrade (E2313). 
 
You asked the Plan to pre-approve codes E2377, E2311, and E2313. You say that the medical records provided 
support the need for the items which remain in dispute.  The Plan denied your request. The Plan says the 
requested upgraded electronics are 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 codes E2377, E2311, and E2313. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has hemiparesis. The enrollee is able to feed herself and groom. The 
enrollee has adequate strength to manage standard power drives.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes E2377, E2311, and E2313 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an expandable controller (E2377), an electronic connection (E2311), and 
a harness upgrade (E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulp cap - indirect (excluding final restoration) 
(D3120). 
  
You asked the Plan to pre-approve dental services. You say that the requested services are needed for the 
enrollee. The Plan denied your request. The Plan says this service is not covered for enrollees over the age of 
20 under your Plan's dental benefits. 
 
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. This benefit includes to pre-
approve pulp cap - indirect (excluding final restoration) (D3120) but this benefit is not covered for enrollees 
over the ages of 0-20. 
 
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 pulp 
cap - indirect (excluding final restoration) (D3120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee. 

You asked the Plan to provide coverage for IRF care. You say that IRF admission was medically necessary.  The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct 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.

The medical records show the enrollee was reported by the hospital therapist to have severe fatigue and weakness. The enrollee refused participation in therapy. There is no indication in the medical records that the enrollee had the ability to participate in the level of therapy provided by an IRF. Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation with limited field of view-less than one whole jaw (D0364) and the pulp vitality tests (D0460) 
provided on February 24,2023. 
  
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam 
computed tomography (CT) capture and interpretation with limited field of view-less than one whole jaw 
(D0364) and the pulp vitality tests (D0460) provided on February 24,2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a push-rim activated power assist system (E0986). 
 
You asked the Plan to pre-approve a push-rim activated power assist system. You say that the item is necessary 
The Plan denied your request. The Plan says the requested item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a push-rim activated power assist system (E0986).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says these items are 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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has adequate strength to manage the standard power drive controls. 
The upgraded electronics are not necessary to meet the enrollee's needs. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics (E2311, E2313, E2377).
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says that you are not appropriate for transfer to an IRF.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our Medical Director states that the documentation does not sufficiently support that you required treatment by multiple therapies and an intensive rehabilitation therapy program with at least 3 hours a day, 5 days a week, or 15 hours over 7 consecutive days, of therapy services, and that there was a reasonable expectation that you would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our Medical Director found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified restorative procedure (D2999) provided on 
January 3, 2023. 
 
You asked the Plan to pay for 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 pay for an 
unspecified restorative procedure (D2999) provided on January 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 25-year full mouth warranty (D0001) and the disposal 
management of human body parts (D0001) provided on July 22, 2022. 
 
You asked the Plan to pay for the full mouth warranty and disposal management. You say that you are 
requesting reconsideration of the denied claim as you had active dental coverage. The Plan denied your request. The Plan says that a 25-year full mouth warranty (D0001) and the disposal management of human body parts 
(D0001) are not covered by 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 Plans 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 pay for a 25-year 
full mouth warranty (D0001) and the disposal management of human body parts (D0001) provided on July 22, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup (D2950) provided on January 19, 2023. 
 
You asked the Plan to pay for a core buildup. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a core 
buildup (D2950) provided on January 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service January 19, 
2023. 
 
You asked the Plan to pay for procedure code 87640. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 87640 is bundled into 
payment for code 87641. 
 
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, we have confirmed that code 87640 
is a column II code to column I code 87641. This claim has not been billed with an appropriate modifier to 
bypass the edit as modifier 59 is not supported. Based on the claim submitted, Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87640 billed for 
date of service January 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services rendered on September 9, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation does not support the original billing.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We asked our 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that based on clinical documentation, the functional status of the enrollee would be appropriately coded as 3GA11. The records do not show that the enrollee was at a medium functional level.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for home health care services rendered on September 9, 2021.