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 the IRF services are medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines, 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 enrollee had an uncomplicated surgery. The enrollee is now functioning at a 
standard level of impairment post surgery. The enrollee's level of function is routinely managed at a skilled 
level of care or lower. The enrollee does not require intensive rehabilitation or complex rehabilitation or 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rytary. 
 
You asked the Plan to pre-approve Rytary. You say that denying this medication will cause harm to the 
patient's stable state, decline and progression of their Parkinson's disease. The Plan denied your request. The 
Plan says that self-administered drugs do not fall under Medicare Part B coverage. 
 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 Rytary.  
 
Benefits for Rytary 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
extremity. 
 
You asked the Plan to pre-approve the MRI. You say that the requested MRI is medically necessary. The Plan 
denied your request. The Plan says the denial of authorization for the MRI is correct, because the enrollee has 
had no additional follow up treatment since the initial visit. 
 
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 MRI of the knee is not shown to be medically necessary or reasonable. Our physician reviewer found 
that the enrollee reported knee pain on August 4, 2023. An initial x-ray showed no acute findings. There is no 
evidence of a physician prescribed plan of care (i.e., prescription medications, physical therapy or occupational 
therapy, or home exercise program). There is no evidence of the enrollee's response to that care. There is no 
evidence of ongoing pain or examination findings. 
 
  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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lower extremity.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care.

You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, you stated that
SNF 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 noted that the medical records show the physical
therapist's notes state at the time of the appeal, you were walking 40 feet and you needed minimum assistance
using a rolling walker. The occupational therapy notes from July 24, 2023, and physical therapy notes from
July 21, 2023, stated you only needed skilled rehabilitation at a frequency of 2 sessions for a duration of one
week. The medical records do not show you required daily skilled nursing and daily skilled therapy services at
an inpatient SNF level of care.

The Plan is correct in this case. 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.
Based on the medical records provided, your care needs at the time of the appeal did not require the level of
services provided in a SNF. Medicare rules for coverage of SNF care have not been met. Therefore, we decided
that the Plan does not have to provide coverage for skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.   
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 clinical documentation shows that you have had clinical and functional status 
change; thus, you would be expected to require assessment by skilled nursing and skilled therapy. The clinical 
documentation shows that your past level of function was modified independent with mobility and self-care 
tasks and currently modified independent/supervision with mobility and self-care tasks; home health care 
services recommended; thus, there are no daily inpatient skilled therapy goals specified. There are no daily 
skilled nursing needs specified thus daily skilled services are not supported. From a practical standpoint, the 
clinical documentation does not support the medical necessity of daily skilled services on an inpatient basis in a 
skilled nursing 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 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: 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 clinical documentation shows that you have had clinical and functional status 
change; thus, you would be expected to require assessment by skilled nursing and skilled therapy. The clinical 
documentation shows that your past level of function was requiring max assist with mobility and self-care tasks 
and requiring max assist with mobility and self-care tasks; thus, there are no daily inpatient skilled therapy 
goals specified. There are no daily skilled nursing needs specified (patient admitted under observation status); 
thus, daily skilled services are not supported. rom a practical standpoint, the clinical documentation does not 
support the medical necessity of daily skilled services on an inpatient basis in a skilled nursing 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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that you tried the oral medications, and they made you sick. 
You say that you had a bone scan which showed that your osteoporosis is getting worse. You also say that you 
are afraid to continue your normal daily activities because if you fall you could break a bone. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred drug, an injectable 
bisphosphonate. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drugs. The reviewer found that there is no indication that the 
Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the requested for Prolia is not medically reasonable or necessary as the step 
therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for transfer from a skilled nursing facility (SNF) to
an acute inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to provide coverage for transfer to IRF care. The Plan denied your request. The Plan says
the 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 noted the medical records show the
enrollee requested a transfer from care in a SNF facility that had expired to an IRF facility. The Plan noted the
enrollee no longer required daily skilled nursing and daily skilled therapy services at an inpatient SNF level of
care. The Plan also noted that during the SNF stay the enrollee declined to participate in therapy regularly and
could only tolerate short periods of physical activity if she did attempt to participate.

The Plan is correct in this case. 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 that at the time of the appeal, the enrollee was not participating in therapy services at the
SNF level of care and did not have the expectation of being willing or able to participate in an IRF level of care
which would be 3 hours a day, 5 days a week. Medicare rules for coverage of a transfer from an expired SNF
admission to IRF admission were not met at the time of the appeal. Therefore, we decided that the Plan does
not have to provide coverage for transfer from a skilled nursing facility (SNF) to an acute inpatient
rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested ventilator is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval of a ventilator. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD and 
obstructive sleep apnea. The enrollee was hospitalized on October 16, 2023, after a fall at home resulting in 
multiple rib fractures, and with a urinary tract infection. Arterial blood gas several days after admission was 
consistent with acute on chronic hypercarbic respiratory failure. There are no recent pulmonary function tests 
to assess the severity of the COPD. There is no diagnosis of thoracic restrictive disease or neuromuscular 
disease. This enrollee may benefit from BiPAP with average volume-assured pressure support (AVAPS) during 
sleep as an outpatient, if compliance can be achieved. Medicare does not cover a home ventilator when used at 
settings that can be provided with BiPAP. The denial is upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy techniques (97140), the therapeutic 
exercises (97110) provided by a chiropractor on January 4, 2023. 
 
You asked the Plan to pay for the manual therapy techniques (97140), the therapeutic exercises (97110). You 
say that the claim should be reprocessed. The Plan denied your request. The Plan says the only covered 
chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the manual therapy techniques (97140), the therapeutic exercises (97110) 
provided by a chiropractor on January 4, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 11, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that after receiving the denial notice from 
Medicare you billed Humana as soon as you could. The Plan denied your request. The Plan says the time limit 
for filing has passed. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance services was not filed until August 1, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the ambulance services provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on August 9, 2023. 
 
You asked the Plan to pay for the core buildup. You say that you were provided a list of network providers 
through the mail and in an email by a plan representative on the phone. You also say that you chose the dentist 
that was close to you, verified they were in-network, and they would take your insurance. The Plan denied your 
request. The Plan says this service is not a covered expense under your dental plan. 
 
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 core buildup, including any pins 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the core buildup, including any pins when required (D2950) provided on August 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay the in-network rate for the medical services provided from June 1, 2023, to June 2, 2023.

You asked the Plan to pay the in-network rate for the medical services provided from June 1, 2023, to June 2, 2023. You say that this provider is in-network. The Plan denied your request. The Plan says the out-of-network 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 30% coinsurance for outpatient diagnostic tests, physician/practitioner services.

You have been asked to pay a 30% coinsurance for the out-of-network medical services provided from June 1, 2023, to June 2, 2023. This service falls within the outpatient diagnostic tests and physician/practitioner services benefit categories. 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. Additionally, the record shows that the provider in this case did not become a contracted provider with the Plan until July 25, 2023. Therefore, we decided that the Plan does not have to pay the in-network rate for the medical services provided from June 1, 2023, to June 2, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 5, 
2023, to July 27, 2023. 
 
You asked the Plan to pay for the SNF care. You say that the services should be covered under the Medicare 
Act. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 5, 
2023, to July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft for ridge preservation  per site 
(D7953) and guided tissue regeneration  resorbable barrier, per site (D4266).  
 
You asked the Plan to pay for bone replacement graft and a guided tissue regeneration. 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 bone replacement graft for ridge preservation  per site (D7953),and guided tissue regeneration  resorbable barrier, 
per site (D4266).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on April 26, 2023, and billed with codes 87640, 87481, 87798, 87500, and 87653. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says per LCA A58747, this type of testing must be billed with a single unit of 
service with a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on April 26, 
2023, and billed with codes 87640, 87481, 87798, 87500, and 87653.