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 it is medically necessary. The Plan denied your 
request. The Plan says you 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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
gastrointestinal bleeding, anemia, and pulmonary embolism. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
You do 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 you 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0835), 
cushioned headrest (E0955), skin protection wheelchair seat cushion (E2603), power seating system, tilt only 
(E1002), 22nf sealed lead acid battery (E2361), retractable or removable mounting hardware for joystick 
(E1028), and electronic connection between wheelchair controller and one power seating system motor 
(E2310).  
You asked the Plan to pre-approve a group 2 standard power wheelchair and additional items and accessories. 
You say that you need a new chair with a tilt seat. You also say that you are unable to use a scooter due to 
nerve damage in your hands. The Plan denied your request. The Plan says at this time, the group 2 power 
wheelchair with accessories is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 2 power wheelchair with power seating 
system, tilt only may be covered if certain 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 2 standard power wheelchair 
and additional items and accessories. Our reviewer says that you do not meet the coverage criteria for a group 2 
standard power wheelchair. Our physician reviewer found you have a complicated history, but you are able to 
walk, and you have normal nerve conduction velocity and electromyography with no muscle atrophy. Our 
reviewer also found that the record does not support that you require a power wheelchair to perform mobility 
related activities of daily living. 
 
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 additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power 
wheelchair (K0835), cushioned headrest (E0955), skin protection wheelchair seat cushion (E2603), power 
seating system, tilt only (E1002), 22nf sealed lead acid battery (E2361), retractable or removable mounting 
hardware for joystick (E1028), and electronic connection between wheelchair controller and one power seating 
system motor (E2310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2750) for teeth #'s 3 and 4.
You asked the Plan to pre-approve crowns. You say that you are requesting a reconsideration of the Plan's
denial. 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 Plan's 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 item or service was exhausted on date of service November 1, 2022.
Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for teeth #'s 3 and 4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to provide coverage for dental services coded as D7210x5, D5221,
D7953x12, and D5222.
You asked the Plan to provide coverage for these dental services . You say that these dental services are
medically necessary. The Plan denied your request. The Plan says the requested services are not covered.
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. The Plan covers dental services when the services are medically necessary and reasonable.
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 requested dental services. Our physician reviewer states the dental records provided consist of the procedure request and dental radiographs with no explanation from the dental provider for the necessity of the requested services or consideration for alternative treatment to show its appropriateness. Medical necessity criteria for the requested services have not been established.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that medical necessity has not been established for the denied services. Therefore, we decided that the Plan does not have to provide coverage for dental services coded as D7210x5, D5221, D7953x12, and D5222.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for dental services coded as D4266, D0380, D7950, D6010, D6066, and D6056 for teeth numbers 20 and 28.
You asked the Plan to provide coverage for these dental services. You say that these dental services are medically necessary. The Plan denied your request. The Plan says these dental services were not demonstrated to be medically necessary. Maximus upheld the Plans denial. After the decision was made it was determined code D4266 was not reviewed.
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. 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 requested dental services.
Our physician reviewer found partial dentures are the standard treatment in this clinical scenario. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided medical necessity has not been established for the dental services requested. Therefore, we decided that the Plan does not have to provide coverage for dental services coded as D4266, D0380, D7950, D6010, D6066, and D6056 for teeth numbers 20 and 28.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
August 25, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract says that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on August 25, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on April 30, 2022.
You asked the Plan to pay for the lab services. You say that these tests were medically necessary and were ordered by the enrollee's treating physician. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim.
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on April 30, 2022.
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 this s the appropriate level of care for the 
enrollee and is medically stable to be transferred to LTACH level of care at this time. The Plan denied your 
request. The Plan says the enrollee is receiving appropriate in-patient 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service December 28, 2022. 
 
You asked the Plan to pay for the lab testing. You say that the referring physician ordered specialized testing. 
The Plan denied your request. The Plan says that the testing must include a unique identifier. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Plan denied services based on a Local Coverage Determination (LCD) 
for Molecular Diagnostic Tests. However, the Plan does not specify which LCD their ruling is based on. 
Furthermore, there is no LCD, or billing guidelines, regarding a unique identifier  for molecular diagnostic tests 
for where the lab services were provided. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request.  Therefore, we decided that the Plan 
has to pay for the lab testing billed for date of service December 28, 2022.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a sleep study provided on December 19, 2022. 
 
You asked the Plan to pay for a sleep study. You say that this is supported in the records. 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 a sleep study provided 
on December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232-24-25-FS billed for date of service 
November 20, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee's condition requires multiple 
services. The Plan denied your request. The Plan says the code is included in the global surgery package. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, the records do not show that 
this evaluation and management services was unrelated to major procedure code 13160. Furthermore, the code 
at issue was billed with inappropriate modifiers. 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 
procedure code 99232-24-25-FS billed for date of service November 20, 2022.
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 is an excellent candidate for acute 
inpatient rehabilitation. You say acute rehabilitation is medically necessary, and the enrollee is motivated to 
improve and return 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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on January 4, 2023, billed with 
code 75710-26-XU-RT. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed 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 75710-26-XU-RT is Angiography, extremity, unilateral, 
radiological supervision and interpretation. 
 
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 the testing services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that in this case, the modifier used is not 
supported in the documentation.  The operative report describes a unilateral extremity angiography, however, 
an intervention was performed, and no documentation was found in report to support a non-overlapping 
service. 
 
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 testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on January 4, 2023, billed with code 75710-26-XU-RT.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99309 for date of service January 2, 2023. 
 
You asked the Plan to pay for procedure code 99309. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 99309 is subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using total time on the date of the encounter for code 
selection, 30 minutes must be met or exceeded. 
 
 
 We find that CPT code 99309 is not supported in the medical record. Specifically, this service was billed with 
diagnosis codes R64 (Cachexia) and R63.4 (Abnormal weight loss). These diagnosis codes should not be 
reported together. This means the claim is not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99309 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99309 for date of service January 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Precision test strips. 
 
You asked the Plan to pre-approve the FreeStyle Precision test strips. You say that you have diabetes and are 
currently using the requested product. The Plan denied your request. The Plan says only the preferred brand 
products listed in the EOC are covered. You must try and fail all preferred blood glucose testing products that 
are covered by your plan. There is no evidence that you have tried and failed a preferred diabetic testing 
supply.  
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the FreeStyle Precision test strips. Therefore, we decided that the Plan does not have to pre-approve 
FreeStyle Precision test strips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on March 11, 2022, billed with 
codes 75625-59, 75716-59, 36245-59, 75726-59, 36252-59, and 36247-LT-59. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 75625-59 and 75716-59 are column II codes to column I code 93458; 
however, 75625-59 and 75716-59 were billed with a modifier.  
 
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 the imaging services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that there is insufficient documentation to 
confirm procedure codes 75625-59 and 75716-59 are distinct procedural services from the column 2 code 
93458. In addition, the Operative report does not include documentation of Codes 36245, 75726, and 36252, 
therefore the billed codes cannot be verified. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on March 11, 2022, billed with codes 75625-59, 
75716-59, 36245-59, 75726-59, 36252-59, and 36247-LT-59.