Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant at surgery services for procedure codes 13101 
and 11603 provided on June 28, 2023. 
 
You asked the Plan to pay for the assistant at surgery services for procedure codes 13101 and 11603. You say 
that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says 
assistant at surgery services are not payable for procedure codes 13101 and 11603. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) codes 13101 and 11603. The Medicare Fee Schedule Database contains a 
surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon 
is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the assistant at surgery services for procedure codes 13101 and 11603 have not been met. Therefore, 
we decided that the Plan does not have to pay for the assistant at surgery services for procedure codes 13101 
and 11603 provided on June 28, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve MRI of the cervical spine. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary to make sure there are no 
underlying structural causes present. The Plan denied your request. The Plan says that the requested imaging is 
not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested imaging is medically necessary. Our physician reviewer found that the enrollee's history, positive 
electromyography (EMG), positive prior MRI in the cervical cord and absent upper extremity reflexes are red 
flags. The requested MRI of cervical spine should be approved. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging MRI of the cervical spine.  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the use of Prolia provided on July 31, 2023. 
 
You asked the Plan to hold you harmless for Prolia. You say that the services should have been covered. The 
Plan denied your request. The Plan says that the service is not covered, and you were notified prior to receiving 
the service. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for Prolia by a contract provider. The file does not show that the Plan provided notice that 
Prolia would not be covered. Under Medicare rules, this means Prolia is considered approved by the Plan. 
Therefore, we decided that the Plan has to hold you harmless for the use of Prolia provided on July 31, 2023.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gabapentin. 
 
You asked the Plan to pre-approve the medication. You say that  requested drug is an essential component of 
the enrollee's treatment plan. The Plan denied your request. The Plan says the medication is not covered as a 
medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gabapentin.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Freestyle Libre 2 for the enrollee.

You asked the Plan to provide coverage for a Freestyle Libre 2 for the enrollee. You say that at the time of the
appeal, a Freestyle Libre 2 was medically necessary. The Plan denied your request. The Plan says there were no
medical records to support the criteria needed for a Freestyle Libre 2 were met at the time of the appeal.
Maximus overturned the Plans denial for no medical records. The Plan requested a reopen and stated it was
clear in the case file that records were requested and were not received.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for this type of device. Medicare rules say that for Medicare to consider coverage and payment for any item or
service, the information submitted by the supplier or provider must corroborate the documentation in the
beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at
the file and Medicare rules. Based on this information, there is insufficient information in the record to
determine if Medicare rules for coverage of this device have been met. Therefore, we decided that the Plan
does not have to provide coverage for a Freestyle Libre 2 for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Vyepti. 
 You asked the Plan to pre-approve Vyepti. You say that Vyepti is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says step-therapy rules for coverage of Vyepti have not been met. 
 
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 Vyepti. Our reviewer says that 
treatment with Vyepti is not medically reasonable and necessary in this case. Our physician reviewer found that 
the Plan requires a trial of drugs Aimovig, Ajovy and Emgality before they will approve the requested drug. In 
this case, the enrollee has not tried and failed the required drugs. There is no documentation provided 
indicating that the Plans required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vyepti have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Vyepti.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs supervision given cognitive 
impairment and lacks the resources to receive any support at home. The Plan denied your request. The Plan 
says the SNF services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily 
basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on June 26, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue 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 CPT code. 
 
 In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer 
found that the records show the enrollee is known to have a history of hallucinations; Therefore, the 
documentation does not support this high level of billing for hallucinations. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on June 26, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the medical records provided support the need for 
care in an SNF. The Plan denied your request. The Plan says enrollee is doing better since admission to 
hospital. The enrollee lives alone and can take care of himself and is able to move around on his own. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test provided on May 5, 2023. 
 
You asked the Plan to pay for the COVID-19 test . You say that the claim denied because the Plan is the 
enrollee's primary payer. You say Medicare does not cover the COVID-19 test after May 11, 2023. The Plan 
denied your request. The Plan says the OTC COVID-19 test is not covered by Medicare after May 11, 2023. 
The Plan says the charges can be submitted to Medicare. 
 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for the OTC COVID-19 test 
after May 11, 2023. Therefore, we decided that the Plan does not have to pay for the COVID-19 test provided 
on May 5, 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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's ongoing skilled therapy and nursing needs can be provided in 
the current skilled nursing facility (SNF).  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the phototherapeutic keratectomy (PTK) provided on July 7, 
2023. 
 
You asked the Plan to pay for the service. You say that  your eye condition needed to be corrected by PTK so 
that an accurate assessment for the correct lenses could be identified. The Plan denied your request. The Plan 
says  this service is not covered. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the service is not to remove a corneal scar. The service is being performed to treat a corneal 
irregularity that would affect the refractive outcome after cataract surgery. As the procedure is considered 
refractive in nature, it is not considered 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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the phototherapeutic keratectomy (PTK) provided on July 7, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on July 17, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue 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 CPT code. 
 
 In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer 
found the documentation supports an appropriate exam, but not an appropriate history or medical decision 
making of high 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 an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on October 27, 2023. 
 
You asked the Plan to pay for physical therapy services. You say that these 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 physical therapy 
services provided on October 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation. provided on August 01, 2023. 
 
You asked the Plan to pay for ambulance transportation.. You say that you would like reconsideration based on 
the records submitted. 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 ambulance 
transportation. provided on August 01, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12011-78 provided on January 5, 2023. 
 
You asked the Plan to pay for procedure code 12011-78. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that physicians report modifier 78 during the global 
surgery post-operative period for services that required a return to the operating room. 
 
We looked at the file and Medicare rules. In this case, the record indicates that the enrollee did not have these 
services performed in the operating room as required by the billing of modifier 78. Based on this information, 
we decided that Medicare rules for coverage of procedure code 12011-78 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 12011-78 provided on January 5, 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 are unable to walk on your own and require IRF 
services to regain your prior level of functioning. The Plan denied your request. The Plan says the request is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.