Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on April 
11, 2023, to July 01, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the service should be 
covered. 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 ambulance service. 
 
You have been asked to pay a $200 copayment for the ambulance services. This item/service falls within the 
ambulance service 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 $400 for ambulance services ($200 copayment X 2 dates of service). 
Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services provided 
on April 11, 2023, to July 01, 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 if the enrollee goes to a lower level of rehabilitation, 
it will compromise the enrollee achieving the highest level of functional outcome. The Plan denied your 
request. The Plan says the IRF services requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a ReActiv8 neurostimulator device 
(64555, 64590). 
 
You asked the Plan to pre-approve a ReActiv8 neurostimulator. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 ReActiv8 neurostimulator. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the ReActiv8 neurostimulator device is experimental for chronic pain. More 
research is needed to demonstrate the device's safety and efficacy. 
 
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 ReActiv8 neurostimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of a ReActiv8 neurostimulator device (64555, 64590).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96401 rendered on March 9, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the prior findings were upheld for CPT 96401. 
 
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 the services have been met. Despite 
multiple attempts from the plan, the provider has not sent in any medical records for this request.. Therefore, 
we decided that the Plan does not have to pay for procedure code 96401 rendered on March 9, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for two units of procedure code 77002 rendered on September 15, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the unit of service for this code is the patient encounter, not number of lesions, number of 
aspirations, number of biopsies, number of injections, or number of localizations. 
 
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 77002 is "Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization 
device) (List separately in addition to code for primary procedure)." 
 
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 services at issue in 
this case were supported by the medical records. Our reviewer found that the record supports two units of 
77002. The record states fluoroscopic guidance was utilized on the right and left sides. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
two units of procedure code 77002 rendered on September 15, 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: 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. You say the 
lower level of care in skilled nursing cannot provide the total interdisciplinary team approach needed. You 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 
enrollee does not meet all the requirements 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
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 therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 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.  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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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 the 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 enrollee does not require LTACH services that are not already available at 
the current facility. There are no services at the LTACH that the enrollee requires that are not already available 
and covered at the current facility. Transfer to the LTACH would not be clinically advantageous and 
completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on September 7, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this drug was medically necessary and should be paid. 
The Plan denied your request. The Plan says this is a packaged service which is not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bupivacaine have not been met. Specifically, bupivacaine is a local anesthetic which would be 
considered integral to, and therefore included in the payment for the injection service or other procedure provided. Therefore, we decided that the Plan does not have to pay for bupivacaine (J3490) provided on 
September 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for code 99153 provided on April 3, 2023.

You asked the Plan to pay for these services. The Plan denied your request. The Plan stated the Medicare
billing criteria were not met.

The Plan follows Medicare rules. Medicare rules say that code 99153 is a "PE" only code and is not payable to
the physician for services provided in the facility setting. Therefore, we decided that the Plan does not have to
pay for code 99153 provided on April 3, 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 requested IRF admission is medically necessary. 
You would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
the notes do not show that the enrollee's care specifically requires the involvement of a doctor in the field of 
Rehabilitation Medicine; the notes do not show that the enrollee has complex care needs that require a 
coordinated team approach; the notes do not show that the enrollee must have an intensive therapy program (3 
hours a day, at least 5 days a week) in order to improve self-care functioning.  
 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's 
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 therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 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. 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: 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 SNF care is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for SNF 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 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 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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network outpatient diagnostic 
test and an out of network and an out-of-network office visit provided on July 31, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network outpatient diagnostic test and an out of 
network and an out-of-network office visit. You say that you disagree with the coinsurance. 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 30% 
coinsurance for out-of-network outpatient diagnostic tests/Medicare-covered radiation therapy service and a 40% coinsurance for out-of-network physician/practitioner services/Medicare-covered visit.  
 
You have been asked to pay a 30% coinsurance for an out-of-network outpatient diagnostic test and a 40% 
coinsurance for and an out-of-network office visit. The total allowed amount for the diagnostic test is $13.45, 
You are being asked to pay is $4.04 ($13.45 x 30% = $4.04). The total allowed amount for the office visit is 
$116.44, you are being asked to pay $46.58 ($116.44 x 40% = $46.58). The total amount you are being asked 
to pay is $50.62 ($46.58 + $4.04 = $50.62). This item/service falls within the out-of-network outpatient 
diagnostic tests/Medicare-covered radiation therapy service and out-of-network physician/practitioner 
services/Medicare-covered visit 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 
an out-of-network outpatient diagnostic test and an out of network and an out-of-network office visit provided 
on July 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Calquence. 
 
You asked the Plan to pre-approve Calquence. The Plan denied your request. The Plan says that self-
administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Calquence.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00811 provided June 30, 2023. 
 
You asked the Plan to pay for the service. You say that you are requesting reconsideration for services advising 
the coding department has reviewed the services and determined that the claim is coded correctly. The Plan 
denied your request. The Plan says the diagnosis codes should not be reported together which is based on the 
Excludes1 Notes instructions in the ICD-10-CM Official Guidelines for Coding and Reporting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Diagnosis codes K63.5 and D12.3 cannot be billed together. These codes billed together demonstrate an 
Excludes1 note that indicates that the code excluded should never be used at the same time as the code above 
the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital 
form versus an acquired form of the same condition. Based on this information, we decided that Medicare rules 
for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 00811 provided June 30, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on 
August 09, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that the service should be 
covered. 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 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for the diagnostic mammogram. This item/service falls within 
the outpatient diagnostic tests and therapeutic services and supplies 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 copayment for the diagnostic mammogram provided on August 09, 2023.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for 750 milligrams (mg) of Testopel for the
enrollee.

You asked the Plan to provide coverage to provide for 750 milligrams (mg) of Testopel for the enrollee.

The Plan denied your request. The Plan says the records provided do not support the dosage requested.
Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the
correct criteria. The Plan noted that the request is for 10 pellets to be implemented at one time which is 4
pellets or 300 mgs above the maximum dose listed in the package insert which exceeds any recommendation
found in the approved drug compendia. The Plan notes the records show the enrollee has never used this
medication before and the provider did not submit any documentation to support the medical necessity for the
requested initial dose.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the medical documentation and confirm that Medicare coverage criteria
have been met. 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 750 milligrams (mg) of
Testopel have been met or why a lesser beginning dose would not be effective. Therefore, we decided that the
Plan does not have to pre-approve 750 milligrams (mg) of Testopel for the enrollee.