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 you are unable to receive acute care while being in 
the hospital bed and continuing to get weaker needing rehabilitation. The Plan denied your request. The Plan 
says your medical condition requires further evaluation and treatment in the current acute care hospital must 
complete your full course of acute hospital treatment.  
 
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 Based on the documentation provided, it is my opinion that the health plans denial 
should be upheld.  The enrollee does not require the intensity of services provided at an IRF.  Specifically, the 
enrollee is not shown to require, or to be able to currently tolerate, fifteen hours per week of rehabilitative 
services and regular physician evaluation.  
 
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 waive the copayment for a lesion removal procedure provided on 
May 10, 2023. 
 
You asked the Plan to waive the copayment for a lesion removal procedure. You say that you disagree with the 
copayment. 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 $200 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $200 copayment for a lesion removal procedure. This item/service falls within 
the in-network outpatient hospital services 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. However, since the allowed amount is less than the standard copayment, 
you only owe $164.51. Therefore, we decided that the Plan does not have to waive the copayment for a lesion 
removal procedure provided on May 10, 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 requesting reconsideration for the denial of 
an IRF admission based on medical necessity. The Plan denied your request. The Plan says the enrollee's needs 
can be met at a lower level of care, such as a skilled nursing facility or home health care.  
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that they meet criteria for admission to an acute 
inpatient rehabilitation facility. The enrollee can receive further services 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: 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 requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare guidelines for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical 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.  
 
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: 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 inpatient rehabilitation will provide the best 
outcome for the enrollee after their stroke. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for admission to an IRF.  
 
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 is medically stable. There are no acute rehab nursing needs identified or 
documented. Document does not support necessity for admission to an IRF. The complexity of the enrollee's 
medical, rehab, and nursing needs does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. The enrollee's rehab needs can be safely provided in an 
alternate and low intensity setting such as 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on January 20, 2022, by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing services. You say that these services were medically necessary. The Plan denied your request. The Plan says that authorization was not obtained for these services. Maximus overturned the Plan's denial because the necessary EOC was not provided. The Plan has now provided the 2022 Evidence of Coverage for review.
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on January 20, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing services provided on January 20, 2022. 
 
You asked the Plan to pay for the testing services. You say that  The Plan denied your request. The Plan says 
that prior authorization was not obtained. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Plan denied the services at issue due to the Plans out-of-network rules. 
We attempted to obtain the Plan contract information for the correct year with no success. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request.  Therefore, we decided that the Plan has to pay for the drug testing services provided on January 
20, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection of lower/sacral spine facet joint. 
 
You asked the Plan to pre-approve an injection of lower/sacral spine facet joint. You say that the enrollee 
previously had radiofrequency ablation/RFA in this area in the past with relief. The Plan denied your request. 
The Plan says the medical 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 an injection of lower/sacral spine facet 
joint. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the member underwent additional L2-L5 diagnostic 
injections on February 27, 2023, which resulted in 60% pain relief and improved mobility. Another diagnostic 
facet joint injection is not needed for this member who has had two prior successful radiofrequency ablation procedures at these levels in the past two years.  
 
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 injection of lower/sacral spine facet joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an injection of lower/sacral spine facet joint.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital transfer to Calvary Hospital. 
 You asked the Plan to pre-approve an inpatient hospital transfer. You say that disagrees with the denial. The 
enrollee has extensive wounds. The Plan denied your request. The Plan says the transfer is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollees 
condition can be managed safely only in the inpatient hospital setting.  
 
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 inpatient hospital transfer. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee was 
admitted to Montefiore Hospital on August 3, 2023, for septic shock and necrotizing fasciitis. The review 
indicates that there is no documentation provided indicating what other specialty care could be provided at 
Calvary Hospital that could not be provided at Montefiore. The enrollee does meet inpatient level of care at 
Montefiore. The review has determined that the items/services at issue in this case were not medically 
reasonable or 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 an inpatient hospital transfer have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient hospital transfer to Calvary Hospital.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 home health skilled nursing visits (G0299 x2). 
 You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented skilled nursing needs.  As such, home heath skilled nursing services are not 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 2 home health skilled nursing visits (G0299 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient services. 
 You asked the Plan to pre-approve continued inpatient services. You say that it is medically necessary to 
continue an inpatient admission. The Plan denied your request. The Plan says the information received dated 
September 6, 2023, indicates the enrollee is medically stable. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollees 
condition can be managed safely only in the inpatient hospital setting.  
 
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 continued inpatient services. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has 
schizoaffective disorder and heart block with pacemaker and was admitted to the hospital with congestive heart 
failure (CHF) and shortness of breath requiring oxygen support, diuresis. Recent notes describe the enrollee as 
now no longer requiring Lasix with stable vitals, stable kidney function, but with persistent delirium, not 
responding to questions appropriately, however, is asking for food and alert. Based on the provided 
documentation, the enrollee appears to be at or near baseline and stable medically enough to be discharged to a 
lower level of care such as a skilled nursing facility. Therefore, this request for ongoing inpatient services will 
be considered not 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 continued inpatient services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ER visit provided on January 1, 2023. 
 
You asked the Plan to pay for an ER visit. You say that you are requesting a review and reconsideration of the 
denied claim. The Plan denied your request. The Plan says the freestanding ER facility is not enrolled in the 
Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an ER visit provided on January 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (82075, 99214) provided on February 23, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 services. Our reviewer says that the use of codes 82075 
and 99214 is not supported by the records provided. Our reviewer found that for code 99214, the procedure 
report does not support the level of service billed.  The medical decision making in this case was 
straightforward. There is a more appropriate code to report for service documented. For code 82075, the 
medical record did not support an alcohol (ethanol) breath test and result.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (82075, 99214) provided on February 23, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99285 billed for dates of service January 5, 2023, to 
January 9, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that code 99285 
merges into the OBS. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
In this case, a claim was not provided. The Plan has not shown what procedure code 99285 is bundled in to. 
The case file shows that the Plan out-of-network criteria was used. The file does not include the Medicare 
billing guidelines the Plan used, if any, in their decision to deny services. The Plan has not made reasonable 
and diligent efforts to gather and forward to us information regarding their decision to deny your request.  
Therefore, we decided that the Plan has to pay for procedure code 99285 billed for dates of service January 5, 
2023, to January 9, 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: 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 is waiting to start therapy to learn to 
walk again and get stronger. The enrollee is currently in bed and losing more muscle tone that would be 
detrimental to health needing to start therapy as soon as possible. The Plan denied your request. The Plan says 
the enrollee's records do not show the need for daily skilled nursing or skilled therapy in a SNF setting. The 
Plan says service required are called custodial care. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne LiquidCDx (0239U) provided July 9, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that the clinical documentation submitted meets 
clinical guidelines and the case should be approved, and payment made. The Plan denied your request. The 
Plan says the records do not support that the criteria has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records do not show that the enrollee's cancer is either recurrent, 
relapsed, refractory, metastatic, or advanced stage III or IV cancer. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the FoundationOne LiquidCDx (0239U) provided July 9, 2022.