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

 
We decided that the Plan does not have to waive the coinsurance for the Synvisc provided on April 14, 2023. 
 
You asked the Plan to waive the coinsurance for the Synvisc. You say that you were not told you would have to 
pay for this injection. 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 20% 
coinsurance for Medicare Part B prescription drugs dispensed by a mail order pharmacy. 
 
You have been asked to pay 20% coinsurance for the Synvisc. This item/service falls within the Medicare Part 
B prescription drugs dispensed by a mail order pharmacy benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The total amount you owe is $276.11, which is less than 20% coinsurance of the allowed amount for this drug. Therefore, we decided that the Plan does not have to 
waive the coinsurance for the Synvisc provided on April 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on September 26, 2023, billed 
with procedure code 99152-59. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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, we have confirmed that code 99152-59 is a column II code to column I code 45385; however, 
99152-59 was billed with a modifier.  
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the documentation does not include 
sufficient documentation to verify 99152 was a distinct, separate, unrelated service from 45385, 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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on September 26, 2023, billed with procedure 
code 99152-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 17, 2023, to June 29, 
2023. 
 
You asked the Plan to pay for psychotherapy. You say that this service is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on January 17, 2023, to June 29, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient admission provided from February 22, 2023, to February 
24, 2023. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the physicians and staff provided 
medically necessary services in the enrollee's best interest. You also say that these services were rendered in 
good faith, and you are requesting the denial be reconsidered and for the claim to be processed for payment. 
The Plan denied your request. The Plan says that none of the criteria for acute inpatient admission are met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found at the time of inpatient admission it was reasonable for the admitting physician to 
expect that the enrollee's necessary hospital care (including earlier emergency department and/or observation 
care) would span two midnights with supporting documentation of the enrollee's history and comorbidities, 
signs and symptoms, current medical needs, and risk of an adverse event. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the inpatient admission provided from February 22, 2023, to February 24, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services rendered on June 13, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered outside of the authorization period. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the file shows that the Plan did not authorize 
acupuncture services beyond June 10, 2023. Therefore, we decided that the Plan does not have to pay for the 
acupuncture services rendered on June 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Anastrozole. 
 
You asked the Plan to pre-approve Anastrozole. You say that the enrollee needs for treatment. 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 Anastrozole.   
Benefits for Anastrozole 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: 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 not ready to discharge home at this 
time. The Plan denied your request. The Plan says the enrollee's records do not show that they require daily 
skilled services that can be provided only on an inpatient basis in a SNF or that they are likely to participate 
with daily skilled services in a SNF.  
 
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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 1, 
2023, to April 2, 2023. 
 
You asked the Plan to pay for SNF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says this SNF stay was not billed with the appropriate number of days.  
The Plan must follow Medicare rules. Medicare rules say that generally, the day of discharge, death, or a day 
on which an enrollee begins a leave of absence is not counted as a utilization day for skilled nursing facility 
(SNF) claims.  
 
We looked at the file and Medicare rules. The record shows that the enrollee was discharged/transferred from 
the SNF on April 2, 2023, but does not show that this discharge met any of the exceptions to the general rule 
that the discharge date does not count as a utilization day. Therefore, this SNF claim was not billed with the 
appropriate number of utilization days. 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 pay for skilled nursing 
facility (SNF) care provided from April 1, 2023, to April 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and comprehensive assessment of and care 
provided on September 28, 2023. 
 
You asked the Plan to pay for an office visit and comprehensive assessment of and care. You say that the 
services were medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
comprehensive assessment of and care provided on September 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical management and rehabilitation 
needs require an IRF admission. The Plan denied your request. The Plan says the enrollee must be able to 
participate in and benefit from intensive rehabilitation therapy, and must complete their 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 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 and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening mammograms provided on August 14, 2023. 
 
You asked the Plan to pay for the screening mammograms. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says The services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules say that for an asymptomatic woman over age 39, payment may be 
made for a screening mammography performed after at least 11 months have passed following the month in 
which the last screening mammography was performed. 
 
Review of the file shows that the enrollee had a routine screening mammogram in December 2022. This 
service is covered after at least 11 months have passed following the month in which the last screening 
mammography was performed. This means the test at issue in this appeal was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the screening mammograms provided on August 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on April 
21, 2023, to June 02, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. 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 $295 
copayment for inpatient hospital care. 
 
You have been asked to pay a $295 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. The total amount you are being asked to pay is $1,475 per stay ($295 x 5 days = $1,475). 
The total amount you are being asked to pay is $2,950 ($1,475 x 2 stays = $2,950). Therefore, we decided that 
the Plan does not have to waive the copayment for inpatient hospital care provided on April 21, 2023, to June 
02, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the brentuximab vedotin injection 
provided on August 3, 2023. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you cannot afford 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 You have been asked to pay $6,138.23, which is less than 20% coinsurance of the allowed amount for the 
injection due to meeting your MOOP amount. 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 brentuximab vedotin 
injection provided on August 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 enrollee currently meets the full criteria for an 
IRF admission. The Plan denied your request. The Plan says the services the enrollee needs can be provided 
safely in other settings, for example, a skilled nursing facility (SNF), at home with home health services or at 
home with outpatient therapy.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
harness (E2313), and expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, and expandable 
controller. You say that you are appealing on the grounds that Medicare has reviewed and approved this 
request. The Plan denied your request. The Plan says the upgraded electronics cannot be covered as it is not 
medically necessary to control the three requested power options through the joystick (drive interface). 
 
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 electronic connection, expandable 
controller harness, and expandable controller. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has 
adult-onset spinal muscle atrophy. The enrollee requires a power wheelchair. Our reviewer found that the 
enrollee has more than 3 to 4 out of 5 strength in in their upper extremity. Our physician reviewer also found 
that this request is not medically necessary as the enrollee has adequate strength to manage standard power 
drives. 
 
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 electronic connection, expandable controller harness, and expandable 
controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), expandable controller harness (E2313), and expandable controller (E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an endoskeletal system, below knee (BK),
alignable system (L5910) for the enrollee.

You asked the Plan to provide coverage for this prosthetic equipment. You say that at the time of appeal this
prosthetic equipment was medically necessary. The Plan denied your request. The Plan says the Medicare
coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated
that Maximus did not apply the correct criteria. The Plan notes that the enrollee has an above the knee
amputation. The requested item coded as L5910 is an alignable system for a below the knee amputation.

Therefore, this equipment cannot be used by the enrollee. The Plan noted that the provider was notified that if
the correct code was submitted it would be reviewed for approval.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the providers
must submit requests for equipment appropriately. It has been confirmed that the requested item, coded as
L5910 is for enrollees with below the knee amputation. The medical records show the enrollee has an above the
knee amputation. Medicare rules for coverage of this prosthetic equipment have been met. Therefore, we
decided that the Plan does not have to provide coverage for an endoskeletal system, below knee (BK), alignable
system (L5910) for the enrollee.