Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary for the enrollee. 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 at the time of the appeal the enrollee was close to baseline.
The enrollee's prior level of functioning was modified independent for mobility with an assistive device.
At the time of the appeal, the enrollee's level of functioning required standby assistance for bed mobility and
minimum assistance for transfers. The enrollee was ambulating 20 ft using a rolling walker. There was no
expectation that the enrollee would be able to participate in or benefit from an IRF level of rehabilitation.

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. Based
on the medical records provided, the enrollee did not meet the criteria required for IRF admission. Whether or
not IRF admission was possibly beneficial is not of issue. The enrollee must meet specific criteria for coverage
at the time of the appeal. Medicare coverage criteria were not met. Therefore, we decided that the Plan does not
have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the
enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tepezza (J3241). 
 
You asked the Plan to pre-approve Tepezza. You say that the patient requires continued treatment with 
Tepezza. The Plan denied your request. The Plan says the requested medication is not an approved drug, and 
the patient does not meet the requirements to have the drug covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Tepezza. Our reviewer says that 
Tepezza is not medically reasonable and necessary for the patient. Our physician reviewer found the review has 
determined that the requested use of Tepezza (J3241) is not FDA-approved for the patients diagnosis. Our 
reviewer also found that its use is not supported by one of the major drug compendia or by clinical research 
that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tepezza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tepezza (J3241).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance transportation. 
 
You asked the Plan to pre-approve the requested services. You say that you need transportation to get to your 
appointments. The Plan denied your request. The Plan says ambulance transport to doctor's appointments is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  We looked at the file and the rules. The services you have asked the Plan to pre-approve are ambulance 
transport services to a doctors office, which is not a covered destination. Additionally, the case file does not 
include documentation to show that other forms of transportation could endanger your health. Therefore, we 
decided that the Plan does not have to pre-approve ambulance transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) on 
tooth #12, 14, the surgical access to an implant body (D6011) on tooth #6, 12, 14, the custom fabricated 
abutment (D6057) on tooth #6, 12, 14, the implant supported crown (D6066) on tooth #6, 12, and the pontic 
(D6251) on tooth #13. 
 
You asked the Plan to pre-approve the dental services. You say that you want to replace your meat-eating teeth. 
The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
surgical placement of implant body (D6010) on tooth #12, 14, the surgical access to an implant body (D6011) 
on tooth #6, 12, 14, the custom fabricated abutment (D6057) on tooth #6, 12, 14, the implant supported crown 
(D6066) on tooth #6, 12, and the pontic (D6251) on tooth #13.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-area office visit provided on July 
11, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-area office visit. You say that this has been your 
prime care doctor for a long time and have not gotten a copayment lie this negotiate 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 40% 
coinsurance for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 40% coinsurance for an out-of-area office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. 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. The total you owe is $64.27. Therefore, we 
decided that the Plan does not have to waive the coinsurance for an out-of-area office visit provided on July 11, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient stay provided on August 
14, 2023, to August 15, 2023. 
 
You asked the Plan to waive the copayment for an acute inpatient stay. You say that you were not given any 
care after being inpatient. You were in pain and could not get any of the staff to help. 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 $290 
copayment for inpatient hospital care.  
You have been asked to pay a $290 copayment for an acute inpatient stay. This item/service falls within the 
inpatient hospital care benefit category. 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. You have been asked to pay a $290 copayment for one day hospitalized. You have not 
been charged for the day you were discharged. Therefore, we decided that the Plan does not have to waive the 
copayment for an acute inpatient stay provided on August 14, 2023, to August 15, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Leqvio. 
 You asked the Plan to pre-approve the medication. You say that you aren't taking anything for high cholesterol 
currently, so you should be able to use Leqvio. The Plan denied your request. The Plan says you have not tried 
the preferred drugs Praluent or Repatha to qualify for the use of Leqvio. 
 
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 the medication. Our reviewer says that 
you do not meet the criteria for Leqvio. Our physician reviewer found in this case, you have not tried and failed 
the required drug(s). There is no documentation provided indicating that the Plans required drug(s) would 
likely be less effective and/or likely have adverse effects for you. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the use of Leqvio.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not 
require 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services and 
these services have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving, but that would be available at the LTACH facility. The elements of coverage 
rules are not satisfied. The requested services cannot be 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services described by code 00560 performed 
on date of service August 14, 2023. 
 
You asked the Plan to pay for 00560. You say that 00560 should be paid as billed because it was a separate 
procedure from any other billed on the same day and was medically necessary. The Plan denied your request. 
The Plan says 00560 is denied because it is bundled into payment for 00563.  
 The Plan must follow Medicare rules. Medicare rules say that payment for anesthesia services associated with 
multiple surgical procedures is determined based on the base unit of the anesthesia procedure with the highest 
base unit value and time units based on the actual anesthesia time of the multiple procedures. 
 
We looked at the file and Medicare rules. In this case we confirmed that 00560 and 00563 were billed on the 
same date of service by providers of the same specialty and group practice, which is considered the same 
provider. We confirmed that a modifier was not appended to either code. We also confirmed that code 00563 
has the higher base unit value in this case. Payment for anesthesia associated with multiple procedures is 
determined based on the base unit of the anesthesia procedure with the highest base unit value and actual 
anesthesia time for the multiple procedures. Providers should report the total time for all procedures in the line 
item with the highest base unit value. Based on this information, we decided that Medicare rules for coverage 
of 00560 have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia 
services described by code 00560 performed on date of service August 14, 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 admission to the IRF is a medical necessity. The 
Plan denied your request. The Plan says based on the available information, admission to IRF is not reasonable 
and necessary, as the enrollee's condition does not meet the Medicare rules.  
 
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 
was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided on December 13, 2022. 
 
You asked the Plan to pay for home health care. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the Notice of Admission (NOA) was not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of home health care have been met. The 
Notice of Admission (NOA) was not submitted to the Plan for review. As the NOA has not been submitted at 
all, it cannot be said that the NOA was submitted within 5 calendar days of the start of care for this period of 
home health care. Therefore, we decided that the Plan does not have to pay for home health care provided on 
December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS Oral Brush CDx Biopsy test provided August 11, 
2023. 
 
You asked the Plan to pay for the laboratory testing. You say that please review medical records and process 
claim for payment.  The Plan denied your request. The Plan says the clinical value and effectiveness of the 
WATS Oral Brush CDx Biopsy test in the setting of disturbance of oral epithelium have not been demonstrated 
in the peer-reviewed literature.  
 
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 laboratory testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the test requisition form documents a raised red gingival lesion. No 
additional medical records were submitted to support medical necessity or documentation to support an 
inability to obtain a scalpel biopsy. The clinical value and effectiveness of the WATS Oral Brush CDx Biopsy 
test in the setting of disturbance of oral epithelium have not been demonstrated in the peer- reviewed literature. 
The review has determined that the items/services at issue in this case are not medically reasonable and 
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 laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the WATS Oral Brush CDx Biopsy test provided August 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on August 9, 2023. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says there is a more appropriate panel code that should be used which is 87799. 
 
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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. The CPT Code Manual definition of code 87500 is 
infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species 
van A, van B), amplified probe technique. The CPT Code Manual definition of code 87798 is infectious agent 
detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. 
The CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA or RNA); 
Candida species, amplified probe technique. The CPT Code Manual definition of code 87653 is infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique. The CPT 
Code Manual definition of code 87641 is infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, methicillin resistant, amplified probe technique. 
 
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 lab tests. Our reviewer says that these codes do not meet 
criteria for payment. Our reviewer found there is a more specific code that should be reported to support these 
services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on August 9, 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 the enrollee is in need of acute rehabilitation services 
to regain strength and independence. The Plan denied your request. The Plan says the services the enrollee 
needs can be provided safely in other settings, for example, a skilled nursing facility (SNF), at home with home 
health services or at home with outpatient therapy.  
 
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 can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is 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, but the services required can be provided at a lower level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual physical exam on September 19, 2023. 
 
You asked the Plan to pay for the annual physical exam. You say that you were not aware that you were not 
due for a physical or that it would not be covered. The Plan denied your request. The Plan says that their 
original decision to deny payment was correct. 
 
The Plan must follow Medicare rules. These rules say that routine physical examinations are not covered. The 
Plan does include coverage for one routine physical examination every 12 months.  
 
Based on review of the file, a routine physical examination was provided less than 12 months prior to the visit 
at issue in this case. Therefore, we decided that the Plan does not have to pay for an annual physical exam on 
September 19, 2023.