Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that your current medical condition requires an IRF level 
of care. The Plan denied your request. The Plan says the enrollee's condition does not meet the requirements for 
an 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 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 multiple therapies, including physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. There is not a reasonable expectation that this 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: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requirements for coverage have not been met. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you have had significant functional and clinical status changes that would be 
expected to require continued assessment by skilled nursing and skilled therapy. You currently require 
maximum assistance with mobility and self-care tasks and are significantly beneath your functional baseline. 
You evaluating therapists recommend ongoing daily skilled therapy for therapeutic treatment and medical 
equipment evaluation in an SNF. You have had multiple medical complications and would be expected to 
require close assessments of vitals and pulmonary status, so daily skilled services are warranted. As a practical 
matter, the clinical documentation supports the medical necessity of daily skilled services on an inpatient basis 
in skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 chiropractic services provided on August 2, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the service is not covered under your contact under 
any normal circumstances. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services provided on August 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the group 2 power wheelchair and the sealed battery to 
be provided by an OON provider.  
 
You asked the Plan to pre-approve the group 2 power wheelchair and the sealed battery. You say that you are 
requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says this service 
is available with in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the group 2 power wheelchair and the sealed battery to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guidance for vascular access (76937), 
transcatheter placement of intravascular stent(s) (37215), and electroencephalogram (EEG) during 
nonintracranial surgery (95955). 
 
You asked the Plan to pre-approve ultrasound guidance for vascular access, transcatheter placement of 
intravascular stent(s), and EEG. You say that the services are necessary. The Plan denied your request. The 
Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that carotid stent placement is covered when specific 
criteria are met. 
 
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 ultrasound guidance for vascular 
access, transcatheter placement of intravascular stent(s), and EEG. Our reviewer says that the services are not 
medically necessary. Our physician reviewer found the rationale for this intervention is unclear. In summary, 
there is insufficient documentation to support the medical necessity for carotid angiography and 
revascularization, accompanied by ultrasound and EEG in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guidance for vascular access, transcatheter placement of 
intravascular stent(s), and EEG have not been met. Therefore, we decided that the Plan does not have to pre-
approve ultrasound guidance for vascular access (76937), transcatheter placement of intravascular stent(s) 
(37215), and electroencephalogram (EEG) during nonintracranial surgery (95955).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says 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 noted the medical records show your ability to participate in therapy was described as
limited by the hospital physical therapist. You needed frequent rest breaks, showed instability, and were unable
to complete the therapy regimen.

The Plan is correct in this case. 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.
Enrollees must be capable at the time of admission to participate in an intensive therapy program for 3 hours a
day, 5 days pers week. Based on the medical records provided, Medicare rules for coverage of IRF care were
not met at the time of the appeal. Therefore, we decided that the Plan does not have to provide coverage for
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 ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record indicates that the enrollee was 
successfully treated with bilevel positive airway pressure (BiPAP). The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with average volume assured pressure support 
(AVAPS) capability and failure of such a device has not been documented. The plan has indicated coverage for 
such a device is available upon request. Furthermore, ventilators fall under the Frequent and Substantial 
Servicing (FSS) payment category, and payment policy requirements preclude FSS payment for devices used to 
deliver continuous and/or intermittent positive airway pressure, regardless of the illness treated by the 
device. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior tibial neurostimulation. 
 
You asked the Plan to pre-approve posterior tibial neurostimulation. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not covered for the enrollee's condition. 
 
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 posterior tibial neurostimulation. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found posterior tibial neurostimulation is necessary when an enrollee has non-
neurogenic voiding dysfunction characterized by urinary frequency, urgency, urge incontinence, and 
nonobstructive retention. In this case, the enrollee has neurogenic bladder dysfunction due to a neurological 
condition.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of posterior tibial neurostimulation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve posterior tibial neurostimulation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found although the enrollee has complaints 
consistent with hypercapnia, there is no compelling evidence to support a home ventilator. There is no arterial 
blood gas analysis (ABG) provided and no failure of bilevel positive airway pressure (BIPAP) with average 
volume assured pressure support (AVAPS) documented. Hence, at this time, does not require a home ventilator 
and a trial of BIPAP with AVAPS would be best practice. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76376-26 billed for date of service May 10, 
2023.  
 
You asked the Plan to pay for procedure code 76376-26. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 76376-26 is bundled into payment for 
code 71275-26. 
 
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 76376-26 is a column two code to column one code 71275-26 with a modifier indicator of 0. The column two 
code is therefore not payable. 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 76376-26 billed for date of service 
May 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a home health physical therapy visit for the
enrollee.

You asked the Plan to provide coverage for a home health physical therapy visit. You say that at the time of the
appeal, this service was medically necessary. The Plan denied your request. The Plan says the services are not
medically necessary. Maximus overturned the Plans denial. The Plan requested a reopen and stated that in the
review, Maximus agreed that the medical records show the enrollee had made maximum potential with skilled
occupational therapy. At that point, the enrollee required moderate to maximum assistance for daily activities
and moderate to maximum assistance for transfers. The occupational therapy notes dated February 28, 2023,
indicated an occupational therapy discharge was completed and the enrollee made maximum potential.

The Plan is correct in this case. 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. Based on the medical records provided, the enrollee
had reached maximum potential. Medicare rules for coverage of a home health physical therapy visit have not
been met. Therefore, we decided that the Plan does not have to provide coverage for a home health physical
therapy visit for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatments of varicose veins. 
 
You asked the Plan to pre-approve treatments of varicose veins. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says it is not medically necessary. 
 
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 treatments of varicose veins. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found it is not clear from the documentation that the patients symptoms are due 
to varicose veins. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of treatments of varicose veins have not been met. Therefore, we decided that the 
Plan does not have to pre-approve treatments of varicose veins.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045-26-77 billed for date of service July 
24, 2023. 
 You asked the Plan to pay for procedure code 71045-26-77. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for code 71045-26-77 is bundled into 
payment for code 32555-LT. 
 
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 
71045-26-77 is a column II code to column I code 32555-LT. This claim 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 71045-26-77 billed for date 
of service July 24, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a knee brace (L1851). 
 
You asked the Plan to pre-approve a knee brace. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, medical records were requested but not received. Without this 
information, the Plan's denial is not able to be substantiated. Therefore, we decided that the Plan has to pre-
approve a knee brace (L1851).  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 You asked the Plan to pre-approve Synvisc. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the plan requires step therapy with one of 
the following: Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. Since none of these have been 
tried, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home 
use (D9630 x 2), the localized delivery of antimicrobial agents via a controlled release vehicle into diseased 
crevicular tissue, per tooth (D4381), gingival irrigation with a medicinal agent-per quadrant (D4921 x 4), and 
an adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and 
malignant lesions (D0431) provided on July 17, 2023 and July 26, 2023. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says these items/services provided are not 
covered under the supplemental dental policy.  
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the items/services provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the drugs 
or medicaments dispensed in the office for home use (D9630 x 2), the localized delivery of antimicrobial 
agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381), gingival irrigation 
with a medicinal agent-per quadrant (D4921 x 4), and an adjunctive pre-diagnostic test that aids in detection of 
mucosal abnormalities including premalignant and malignant lesions (D0431) provided on July 17, 2023 and 
July 26, 2023.