Persius/hicric huggingface dataset:
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's acute care needs are LTACH 
appropriate, and can be met and monitored at a LTACH level of care at this time. The Plan denied your request. 
The Plan says the enrollee does not meet the requirements for a LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 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 medical record indicates that the enrollee has ongoing acute medical issues and 
still requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving, but that would be available at the LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you believe these orthotics should be covered. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and attachments
for the enrollee.

You asked the Plan to pre-approve a Group 3 power wheelchair and attachments. You say that without the
power wheelchair, the enrollee's mobility would be severely limited. The Plan denied your request. The Plan
says that the enrollee does not have medical need for the multiple power options included with the requested
K0861 Group 3 power wheelchair with multiple power options.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Group 3 power
wheelchair and attachments. Our Medical Director states that the enrollee has Parkinson's disease. On January
16, 2023, the enrollee was using a rollator walker due to unsteady gait and balance. He was requesting a
trapeze bar for repositioning while in bed. The available clinical documentation does not support that the
enrollee requires power tilt and power recline. The notes do not show that upgraded electronics (expandable
controller, harness, and electronic connection) are medically necessary for this enrollee. Our Medical Director
found that the enrollee's condition does not meet criteria for coverage of a Group 3 power wheelchair and
attachments.

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 3 power wheelchair and attachments have not been met. Therefore, we
decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and attachments for
the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abdominal panniculectomy and a reduction 
mammoplasty. 
 
You asked the Plan to pre-approve an abdominal panniculectomy and a reduction mammoplasty. You say that 
the enrollee would benefit from these procedures. The Plan denied your request. The Plan says the medical 
criteria needed for the requested cosmetic surgery has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 an abdominal panniculectomy and a 
reduction mammoplasty. Our reviewer says that these procedures are not medically necessary. Our reviewer 
found records do not document complicating factors as inability to walk normally due to pannus size, chronic 
pain, ulceration created by the abdominal skin fold, or chronic refractory dermatitis of at least three months. 
Provided records do not document breast pain or tenderness directly related to the breast tissue which has a 
clinically significant impact upon activities of daily living that is refractory to a trial of analgesics or anti-
inflammatory agents. Records do not document the excessive breast weight adversely affects the supporting 
structures of the shoulders, neck and trunk. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an abdominal panniculectomy and a reduction mammoplasty have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an abdominal panniculectomy and a 
reduction mammoplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bladder instillation of anticarcinogenic agent (51720) 
provided on June 8, 2023. 
 
You asked the Plan to pay for the bladder instillation of anticarcinogenic agent (51720). You say that the 
enrollee had a 6-month injection and the documentation supports the billing of procedure code 51720. You say 
that the claim should be reviewed and reconsidered for payment. The Plan denied your request. The Plan says 
the records do not support that this procedure was performed. 
 
  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 51720 is bladder instillation of anticarcinogenic agent 
(including retention time). 
 
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 bladder instillation of anticarcinogenic agent (51720). 
Our reviewer says that procedure code 51720 is not supported. Our reviewer found the documentation does not 
contain a procedure note supporting that an instillation of an anticarcinogenic agent in the bladder was 
performed. Therefore, this service 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 bladder instillation of anticarcinogenic agent (51720) have not been met. 
Therefore, we decided that the Plan does not have to pay for the bladder instillation of anticarcinogenic agent 
(51720) provided on June 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft (21085, 21026, 21210, 21209). 
 
You asked the Plan to pre-approve a bone graft. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 pre-approve a bone graft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found while the enrollee has symptoms that meet the criteria (difficulty eating/chewing, duration >6 
months, problems speaking), there is insufficient documentation of deformity/alignment to meet criteria for 
coverage.  
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 bone graft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bone graft (21085, 21026, 21210, 21209).
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 needs IRF services as she is home alone 
and is a fall risk. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
an IRF admission.  
 
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 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 this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF, but 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: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for code 22852 billed to the enrollee for June 21, 2022.

You asked the Plan to pay for code 22852. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial stating
the records show the services billed were supported by the medical record. The Plan requested a reopen and
noted this was not a medical necessity denial but a technical billing denial. The Plan demonstrated that code
22852-AS-59, removal of posterior segmental instrumentation is considered inclusive to code 22840-AS. The
documents received do not support that the procedure or service was distinct or independent from other
services performed; therefore, the requested code modifier is not supported. The Plan shows that code 22852 is
a column 2 status to code 22840, an approved column one code. These procedures occurred in the same
incision, one the same day, on adjacent spinal segments, by the same surgeon and in fact the removal
was integral to the insertion such that the new hardware included replacement at some of the removed
levels. The documents received do not support that the procedure or service was distinct or independent
from other services performed. The documentation must support a different session, different procedure or
surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of
injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.

The Plan is correct 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 code. In this case, the Plan has
demonstrated that code 22852 could not be paid as billed due to its relationship to code 22840. Medicare rules
for coverage of code 22852 have not been met. Therefore, we decided that the Plan does not have to pay for
procedure code 22852 billed to the enrollee for June 21, 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 will not get the therapy they need if they 
do not go to the rehab center that is closer to them. The Plan denied your request. The Plan says the inpatient 
rehabilitation facility (IRF) services you are requesting 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. 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 this 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total disc arthroplasty. 
 
You asked the Plan to pre-approve a total disc arthroplasty. You say that the enrollee is a good candidate for a 
disc arthroplasty because they have greater than 50%-disc height management. You say that you recommend a 
total disc arthroplasty at C4/5 to address the stenosis and preserve motion to reduce the likelihood of future 
surgery at the healthy adjacent level. The Plan denied your request. The Plan says a cervical disc replacement is 
considered investigational when there is a previous fusion at another level and when combined with the use of 
an artificial cervical disc and fusion. 
 
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 pre-approve a total disc arthroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a cervical disc replacement is considered experimental when combined with a fusion. 
 
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 total disc arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total disc arthroplasty.
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 services are medically necessary for you to 
rebuild your strength after being hospitalized. The Plan denied your request. The Plan says your records do not 
show that you have the activity tolerance or strength to take part in extensive therapy services.  
 
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 you do not require treatment by multiple therapies. 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: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit (procedure code 99282) provided on 
May 12, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure code 99282). You say that procedure 
code 99282 is appropriate based on the services performed. The Plan denied your request. The Plan says that 
the enrollee's diagnosis is not appropriate for emergency care. 
 
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 99282 is emergency department visit for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and straightforward 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 code 99282). Our 
reviewer says that the services at issue in this case are supported by the medical records. Our reviewer found 
the documentation contains an appropriate history and physical examination. The medical decision making is 
straight-forward. As such, the billing of CPT 99282 is supported. 
 
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 code 99282) have been met. 
Therefore, we decided that the Plan has to pay for an emergency department visit (procedure code 99282) 
provided on May 12, 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 waive the coinsurance for the Omalizumab injections provided from
November 29, 2022, to December 13, 2022.

You asked the Plan to waive the coinsurance for these services. You say that you disagree with the cost share.
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 20%
coinsurance for Medicare Part B prescription drugs.

Review of the file shows that you received Omalizumab injections from November 29, 2022, to December 13,
2022. The previous determination stated that the Plan had to waive the coinsurance because you were asked to
pay the full allowed amount; however, this determination was incorrect. The full allowed amount is the full
amount that a provider can bill based on Medicare rules. The full allowed amount for these services was
$5,798.30. A 20% coinsurance for this amount equals $1,159.66. The Plan has asked you to pay a total of
$792.95 for these services, which is less than the 20% coinsurance. This item/service falls within the Medicare
Part B prescription drugs 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. Therefore, we decided that the Plan does not have to waive the coinsurance for the
Omalizumab injections provided from November 29, 2022, to December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5213) and a mandibular partial 
denture (D5214) provided on July 12, 2023. 
 
You asked the Plan to pay for the dentures. You say that you were taking your partial teeth out when you 
dropped them on the floor. You say you need new teeth as the ones that are missing are in the very front of 
your mouth. 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 Plans 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 April 30, 2021 when you 
received a maxillary partial denture (D5211) and a mandibular partial denture (D5212). Therefore, we decided 
that the Plan does not have to pay for a maxillary partial denture (D5213) and a mandibular partial denture 
(D5214) provided on July 12, 2023.