Persius/hicric huggingface dataset:
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's condition has declined 
since the original decision and will most likely need acute care. The Plan denied your request. The Plan says 
the enrollee does not meet the requirements for an 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 appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) scan of the abdomen and both lower extremities.
You asked the Plan to pre-approve this imaging. You say that at the time of the appeal, this imaging was medically necessary. The Plan denied your request. The Plan says while the imaging of the abdominal aorta was appropriate, the imaging of both lower extremities was not demonstrated to be necessary. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. Maximus made an error in the explanation of the original decision. The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. Our physician reviewer basically agreed with the Plans decision. Our physician reviewer found you have a history of "known descending aortic aneurysm having increased in diameter from 3.1-3.8 cm". However, no ultrasound report was submitted. CTA of the abdominal aorta with runoff would be appropriate due to an increase in the aneurysm. There is not documentation submitted showing the medical necessity of imaging of both lower extremities.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) scan of the abdomen and both lower extremities.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on February 22, 2023. 
 
You asked the Plan to pay for the home visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies billed for date of service 
January 3, 2023. 
 
You asked the Plan to pay for the billed services. You say that the items are essential for use with the electrical 
stimulator unit.  The Plan denied your request. The Plan says the supplies for a non-covered device are non-
covered as well.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes A4556, A4557, and A4630 were supplies billed for a TENS unit. The TENS unit was 
requested for treatment of chronic low back pain. TENS therapy for Chronic Low Back Pain (CLBP) will be 
denied as not reasonable and necessary. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
electrical stimulator supplies billed for date of service January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the elite cervical orthosis (L0180) provided to the enrollee on July 8, 2022.
You asked the Plan to pay for the orthosis. You say that the item was medically necessary for the enrollee. The Plan denied your request. The Plan says that the submitted documentation does not sufficiently support the billed code.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid physician order, proof of delivery and relevant medical records which support medical necessity.
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The medical records provided do not discuss the need for this item. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the elite cervical orthosis (L0180) provided to the enrollee on July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided to the enrollee on September 28, 2022.
You asked the Plan to pay for the electrical stimulator supplies. You say that this claim was billed correctly. The Plan denied your request. The Plan says that the provider did not submit any evidence that they have been contacting the member before shipping additional supplies. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that for all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary. We looked at the file and Medicare rules. The file does not include any documentation that there was contact between the supplier and beneficiary prior to the electrodes begin dispensed. Based on this information, we decided that Medicare rules for coverage of the electrical stimulator supplies have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided to the enrollee on September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a FQHC visit provided on August 25, 2022, by an out-of-
network OON provider.  
 
You asked the Plan to pay for FQHC visit. You say that you are requesting reconsideration of the denied claim. 
The Plan denied your request. The Plan says this service was not authorized. 
 
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 a FQHC visit provided on August 25, 2022, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutment (D6057) and abutment support 
(D6059). 
 
You asked the Plan to pre-approve custom abutment and abutment support. 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 pre-approve 
custom abutment (D6057) and abutment support (D6059).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80048 and 96361 billed for date of service 
January 1, 2023, to January 4, 2023.  
 
You asked the Plan to pay for procedure codes 80048 and 96361. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says payment for code 80048 
is bundled into payment for code 80053. Code 96361 is an add-on code which was billed without an 
appropriate primary procedure. 
 
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 80048 
is a column II code to column I code 80053 with a modifier indicator of 0. The column II code is therefore not 
payable. In addition, we have confirmed that code 96361 is an add-on code and has not been billed with an 
appropriate primary procedure code. 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 codes 80048 and 96361 billed for date 
of service January 1, 2023, to January 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
March 9, 2023, to March 11, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this is too much money 
to pay at once. 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 $380 
copayment per day for days 1-5 of each inpatient hospital stay. Your contract with the Plan also clearly says 
that you then pay a $0 copayment per day for any additional days of the same inpatient hospital stay. You have been asked to pay a $380 copayment per day for days 1-2 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay after day 
two or for the day you were discharged. You have been asked to pay a total of $760 ($380 copayment per day x 
2 days = $760). 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 the inpatient hospital stay provided from 
March 9, 2023, to March 11, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to your medical appointments. The Plan denied your request. The Plan says you have utilized the maximum 
number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit and services provided on 
March 18, 2023. 
 
You asked the Plan to pay for the emergency department visit and services. You say that you would like this 
claim to be reprocessed. The Plan denied your request. The Plan says the provider confirmed they are not 
enrolled with Medicare.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency department visit and 
services provided on March 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 24, 2023. 
 
You asked the Plan to pay for the office visit. You say that it is the facilitys responsibility to confirm coverage. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on January 24, 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 you need inpatient rehabilitation to get better and go 
home. The Plan denied your request. The Plan says based on the available information, admission to IRF is not 
reasonable and necessary, your condition does not meet the Medicare requirements. Services needed may be 
provided safely in a lower level of care. 
 
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records support admission is 
based on medical necessity.  The Plan denied your request. The Plan says according to the information 
reviewed on appeal, the requested service is not medically necessary.  
 
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 there is no evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals (ACH) are licensed to provide the same level of care, there is not 
advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can 
then be transferred/discharged to a lower level of care for any ongoing LTC 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the robotic-assisted surgery provided on 
January 11, 2023. 
 
You asked the Plan to provide reimbursement for the robotic-assisted surgery. You say that you are requesting 
reconsideration of the denied reimbursement. The Plan denied your request. The Plan says this facility is not 
enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to provide reimbursement for the robotic-assisted 
surgery provided on January 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 home health physical therapy (G0151) and 5 home 
health skilled nursing visit (G0299). 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
was independent with self-care, transfers, ambulation. Continued skilled services were 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 home health physical therapy (G0151) and 5 home health skilled nursing visit 
(G0299).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services on February 13, 2023, billed with codes 
74230, 72040, 70100, 70310, 71045, and 74240. 
 
You asked the Plan to pay for the radiology services. You say that the Plan should cover the radiology services 
as billed. The Plan denied your request. The Plan says this claim was billed with an inappropriate POS.   

The Plan must follow Medicare rules. Medicare rules say that claims must be billed to the appropriate POS.  
 
We looked at the file and Medicare rules. This claim was billed with POS 11, indicating an office setting. 
However, documentation shows the radiology services were performed in a mobile setting. There is no 
evidence the services were provided in an office setting. Based on this information, we decided that Medicare 
rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not 
have to pay for radiology services on February 13, 2023, billed with codes 74230, 72040, 70100, 70310, 
71045, and 74240.
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 services are medically necessary. The 
Plan denied your request. The Plan says the enrollee's needs can be provided in the current hospital setting. 
 
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. The 
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.