Persius/hicric huggingface dataset:
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 want your doctor to be able to watch 
your oxygen level and infection status closer. You say you can benefit from therapy in hopes of returning home 
and not getting sicker if discharged too soon.  The Plan denied your request. The Plan says the LTACH 
services are not medically necessary, and your care can be met at a lower level of care such as a skilled nursing 
facility. 
 
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 you have a history of coronary artery disease, hypertension who presented with fever and cough. You were diagnosed with pneumonia and treated with antibiotics. You are receiving appropriate 
care in current acute care setting as provided by Health Plan. The documentation does not support that LTACH 
services are medically appropriate at this time. 
 
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: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99285 for date of service May 17, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the code billed is 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. In this case, the CPT Code Manual definition of 
code 99285 is Emergency department visit for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making. 
 
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 procedure code 99285. Our reviewer says 
that the documentation supports the code billed. Our reviewer found the enrollee presented to the Emergency 
Department with epigastric abdominal pain. Broad differential by physician, labs and computed tomography 
was ordered. The history and physical exam support high level of medical decision making. Therefore, code 
99285 is supported. 
 
We looked at this reviewer's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99285 for date of service May 17, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records provided support the 
need for the requested LTACH admission. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet all the requirements for 
LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 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 has myotonic dystrophy who was admitted for syncope, acute 
myocardial infarction, new onset atrial fibrillation, and acute respiratory failure.  The enrollee required a tracheostomy and percutaneous endoscopic gastrostomy (PEG) placement. The 
documentation from November 29, 2023 notes that he is critically ill and is requiring intensive care unit care. 
The documentation also notes progressive improvement in pressure support requirements during spontaneous 
breathing trials, but that his myotonic dystrophy prognosis (and the implications for ventilator weaning) are 
poor. In the absence of more progress on ventilator weaning, it is unclear if vent wean will be possible. 
 
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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for discharge to 
another facility. The Plan denied your request. The Plan says they will continue to cover the acute and critical 
care at the current facility until the enrollee is stable for discharge. 
 
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 is not done with their acute care hospitalization and does not meet 
criteria for LTACH. 
 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 LTACH 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 the services are medically necessary to give the 
enrollee the chance to receive the services needed before returning home. 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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied CGM and that the services requested are medically necessary. The Plan 
denied your request. The Plan says the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that solely display results on a 
smartphone and do not have a stand-alone receiver or integration into an infusion pump do not meet the 
definition of DME and will be denied as non-covered (no benefit). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM).
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 has been bed ridden after a fall and 
requires therapy services. 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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 3 sensors. 
 
You asked the Plan to pre-approve the Freestyle Libre 3 sensors. The Plan denied your request. The Plan says 
this request does not meet Medicare criteria as you are not on insulin and have no history of problematic 
hypoglycemia.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the Freestyle Libre 3 sensors. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found the record indicates that 
you have diabetes. The record provided does not indicate that you are being treated with insulin or have 
problematic hypoglycemia as defined by the Medicare rules. The elements of coverage criteria are not satisfied.  
 
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 Freestyle Libre 3 sensors have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Freestyle Libre 3 sensors.
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 feel more aggressive rehabilitation will enable 
you to return home quickly. The Plan denied your request. The Plan says your records do not show that you 
need to be seen by a rehabilitation doctor at least 3 times a week, you are not 
able to take part in 3 hours of therapy a day at least 5 days a week or 15 hours per week and you do not 
need an intensive team for your 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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do 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 you 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown teeth 24, 27 (D6750), and a pontic teeth 
25, 26 (D6240). 
 
You asked the Plan to pre-approve retainer crowns and a pontic. You say that you had two teeth extracted to 
complete a dental job and because it has not been finished, you cannot eat and are losing weight. The Plan 
denied your request. The Plan says the provided clinical and/or x-ray information, shows there are not 
favorable conditions in the tooth to execute the requested procedure. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers retainer 
crowns and a pontic when the services are medically necessary and reasonable.  
 
 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 retainer crowns and a pontic. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the bridge from #27-24 
is not reasonable or medically necessary. There is 80% bone loss on tooth #24 and approximately 50% bone 
loss on #27. To have adequate support for supporting a bridge including missing teeth, an abutment must have 
at least 50% bone remaining. In this instance there is inadequate bone support remaining to allow for the 
requested bridge to function properly with a reasonable long-term prognosis. Due to the severe periodontal 
involvement and bone loss around tooth #24 the requested procedure would have a very poor long-term 
prognosis. Due to the poor prognosis of the requested procedure, the Plan criteria would not be met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of retainer crowns and a pontic have not been met. Therefore, we decided that the 
Plan does not have to pre-approve retainer crown teeth 24, 27 (D6750), and a pontic teeth 25, 26 (D6240).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this level of care The Plan denied 
your request. The Plan says medical records do not support the need for an IRF admission and, the enrollee 
needs can be provided at another setting.  
 
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 medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 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 observation care services (99224, 99234) billed
for dates of service from October 22, 2022, to October 23, 2022, under Claim A.

You asked the Plan to pay for Claim A. You say that this claim should be paid. The Plan denied your request.
The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. Maximus
overturned the Plans denial. The Plan requested a reopen and provided additional claim information.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that claims or claim lines
that have been determined to be exact duplicates of another claim or claim line are denied. The Plan submitted
Claim B which shows previous payment for this service was already submitted and paid. Therefore, we decided
that the Plan does not have to pay for observation care services (99224, 99234) billed for dates of service from
October 22, 2022, to October 23, 2022, under Claim A.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external ambulatory infusion pump. 
 
You asked the Plan to pre-approve the external ambulatory infusion pump. You say that you have had your 
insulin changed several times to help lower your blood sugar, but it is not working. The Plan denied your 
request. The Plan says the Medicare coverage criteria was not met. 
 
The Plan follows Medicare rules. Medicare rules say that for an external ambulatory infusion pump to be 
covered there must be documentation of the C-peptide results or a positive Beta cell autoantibody test. 
 
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 external ambulatory infusion pump. 
Our reviewer says that the coverage criteria was not met. Our physician reviewer found that the record 
provided does not document the results of a C-peptide or Beta cell autoantibody test. The elements of the 
coverage criteria are not satisfied. The requested service is not 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 external ambulatory infusion pump have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an external ambulatory infusion pump.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service June 9, 2023. 
 
You asked the Plan to pay for procedure code 99291. You say that the code routinely pays. The Plan denied 
your request. The Plan says payment for code 99291 is bundled into payment for code 33620. 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 99291 is a column II code to column I code 33620. Code 99291 has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99291 
billed for date of service June 9, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates for service April 5, 
2023, to April 14, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says the claim was not billed correctly. 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 looked at the file and the rules. The claim at issue was not billed with a Q code as required. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for the home health care billed for dates for service April 5, 
2023, to April 14, 2023.