Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 skilled nursing visits, 8 physical therapy visits and 8 
home health aide visits. 
 
You asked the Plan to pre-approve home health services. You say that the services requested are medically 
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 requested services are not medically reasonable and necessary. Our physician reviewer found that 
the enrollee is noted to have stable vital signs. The enrollee does not require wound care, catheterization, G-
tube feeding, or administration of IV or complex medications. The enrollee is eating and drinking three times 
per day. The enrollee is modified independent with transfers and requires supervision when ambulating 150 
feet with a walker. The allocated 2 skilled nursing visits, 4 physical therapy visits, and 6 home health aide visits 
should be sufficient to transition the enrollee and the enrollee is noted to have family assistance available. 
 
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 4 skilled nursing visits, 8 physical therapy visits and 8 home health aide visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the stent placement rendered on October
25, 2022.

You asked the Plan to waive the coinsurance for these services. You say that you were unaware of the
coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus
overturned the Plans denial. The Plan requested a reopen and provided additional information.

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 20% of
the total cost for in-network Medicare-covered diagnostic tests (i.e., EKG and EEG).

Review of the file shows that you received a stent placement on October 25, 2022. The previous determination
stated that the incorrect coinsurance was applied; however, the EOC clearly states that there is a 20%
coinsurance for these services. 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 stent placement rendered on October
25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 3, 2023 to July 28, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 3, 
2023 to July 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full mouth debridement to enable comprehensive oral 
evaluation (D4355) provided on June 28, 2023. 
 
You asked the Plan to pay for full mouth debridement to enable comprehensive oral evaluation (D4355). You 
say that you believe the Plan could downgrade the procedure from a full mouth debridement (D4355) to an 
adult prophylaxis (D1110) and reimburse you for what you normally pay for an adult prophylaxis (D1110). The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for full 
mouth debridement to enable comprehensive oral evaluation (D4355) provided on June 28, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 has been denied skilled nursing facility 
services and is not in any shape to return home independenty. 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall significantly complies with the various documentation requirements for IRF 
admission. The enrollee's condition is complex and fragile, and there is every reason to expect that they will 
participate in and benefit from IRF-level services to include at minimum physical and occupational therapy, 
nutritionist, physician oversight of wound vac function and polypharmacy, and case manager coordination of 
any additional services that might be needed to make a sustainable return, as well as avoid further preventable 
readmissions to the acute hospital. It is highly unlikely that the enrollee's complex needs could be met at a 
lower level of care. Therefore, the requested inpatient rehabilitation facility admission is approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921). 
 
You asked the Plan to pre-approve periodontal scaling and root planing (D4341). You say that if left untreated, 
your teeth will fall out as the gums will no longer support them. The Plan denied your request. The Plan says 
gingival irrigation (D4921) is not covered. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation (D4921).
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 meets full IRF criteria. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for 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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement; however, the documentation 
does not support that the enrollee would meet criteria for admission to an acute inpatient rehabilitation 
facility. There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in 
rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to 
regain or maintain their functional status. 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 pay for inpatient hospital services provided on January 15, 2023, to 
January 23, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
diagnosis of E43 (Unspecified severe protein-calorie malnutrition) is supported by the medical record, and the 
original DRG billed should be paid. The Plan denied your request. The Plan says although the diagnosis of E43 
(Unspecified severe protein-calorie malnutrition) is documented, sufficient supporting documentation was not 
found within the medical record to validate this diagnosis based on clinical criteria. As a result, a lower DRG 
was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with E43 (Unspecified severe protein-calorie 
malnutrition). 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 inpatient hospital 
services at the DRG originally billed. Our physician reviewer found the documentation does not consistently 
and completely support the assigned secondary diagnosis code. The decision to remove the secondary diagnosis 
code and adjust the DRG is upheld.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 15, 2023, to January 23, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 26, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 heavy duty power operated vehicle (K0807). 
 
You asked the Plan to pre-approve a Group 2 heavy duty power operated vehicle. You say that you feel the 
Plan should cover the electric scooter so you can have somewhat of a normal life and be able to participate in 
some venues. The Plan denied your request. The Plan says this request does not meet Medicare requirements 
for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that Group 2 POVs (such as code K0807, K0808) 
have added capabilities that are not needed for use in the home, and will be denied as not reasonable and 
necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Group 2 heavy duty power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 2 heavy duty power operated vehicle (K0807).
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 requested IRF services are necessary for you to 
be able to discontinue the use of your wheelchair and return to using your walker. The Plan denied your 
request. The Plan says that you do not have complex rehabilitation, medical, and nursing needs. You do not 
need to be assessed medically and functionally under the supervision of a rehabilitation doctor with face-to-
face visits at least three days per week. You do not need three hours of therapy per day or 15 hours per week. 
You do not need specialized training, staff, or equipment available only in 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 your nursing, medical and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement; however, the documentation does not support that you 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you 
would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain your functional status. You 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: Drugs
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the enrollee would like to try new treatment. 
The Plan denied your request. The Plan says a home ventilator is not medically necessary for this enrollee 
because their needs can be met with an alternative device such as a BiPAP device with average volume-assured 
pressure support (AVAPS).  
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 the ventilator. Our physician reviewer 
found there is no diagnosis of thoracic restrictive disease or neuromuscular disease. This enrollee may benefit 
from BiPAP with AVAPS during sleep as an outpatient. 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator (E0466).
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 the ventilator. You say that this is needed to provide the best care for the 
enrollee. The Plan denied your request. The Plan says the records indicate that this device is to be used solely 
as a respiratory assist device. 
 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 the ventilator. Our physician reviewer 
found the enrollee tolerated BiPAP in hospital until diuresis took effect and improved respiratory status. At this 
time, the enrollee tolerated BiPAP and improved; hence, the documentation does not support the home 
ventilator. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair with a patient 
weight capacity 301 to 450 pounds (K0825), two lead acid batteries (E2361 x2), and two detachable arm rests 
(E0973 x2). 
 
You asked the Plan to pre-approve a group 2 heavy duty power wheelchair, two lead acid batteries, and two 
detachable arm rests. The Plan denied your request. The Plan says the documentation does not support the 
medical necessity for this service, in that the enrollee's weight is less than 300 pounds. 
 
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered if the beneficiarys weight is 
less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 
95% of the weight capacity of the next lower weight class PWC. Medicare rules also say if the base PWC is not 
covered, then related accessories will be denied. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 2 heavy duty power wheelchair, two lead acid batteries, and two detachable arm rests have 
not been met. Specifically, the provided records show that the enrollee's most recent documented weight is 
below the required weight limit of 301 to 450 pounds for a group 2 heavy duty power wheelchair (K0825). 
Therefore, we decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair with 
a patient weight capacity 301 to 450 pounds (K0825), two lead acid batteries (E2361 x2), and two detachable 
arm rests (E0973 x2).