Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit services to be provided by an out-of-network 
(OON) orthopedic surgeon.  
 
You asked the Plan to pre-approve the office visit services with an OON orthopedic surgeon. You say that the 
network provider you saw is unable to help you. You say that you had a hip replacement in the left hip, have 
done research, and know that you hip did not heal the right way. You say that the muscle did not wrap 
correctly, and you don't think the hip replacement was done correctly.  The Plan denied your request. The Plan 
says there are other orthopedic surgeons, besides the one you previously saw, who are within their network 
who would be able to treat your condition. 
 
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 
office visit services to be provided by an out-of-network (OON) orthopedic surgeon.
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 physical therapy only comes once a day. You say 
they do not have a diabetic menu and the enrollee's primary doctor does not come here. 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: 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 the enrollee requires a LTACH level of 
care and is stable for discharge. The Plan denied your request. The Plan says the records do not show the 
enrollee's continued treatments can only take place in a hospital setting. The Plan says the enrollee needs to 
complete treatments in the current hospital. 
 
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 services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Given there are offered alternatives, LTACH is not 
medically 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 02, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was 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 the laboratory services 
provided on June 02, 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 you are requesting reconsideration for acute therapy 
to come back home and have some quality of life. 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 your 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: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 15002, 15004, and 97606. We decided that the Plan 
does not have to pay for procedure codes 15100, 15120, 28005, 15275, 15271, and 15272.  
 
You asked the Plan to pay for the assistant at surgery services provided on June 9, 2023. You say that the 
services were necessary. The Plan says that the claim denied appropriately. 
 
We decided that the Plan has to pay for procedure codes 15002, 15004, and 97606.  
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
We looked at the file and the rules. In this case, the record does show that the provider of the surgical assistant 
service is a PA. The services were billed with both the AS and 82 modifiers. Modifier AS is billed to indicate 
that a PA, NP, or CNS served as the assistant at surgery. Modifier 80, 81 or 82 must also be billed when 
modifier AS is billed. Based on this information, we decided that the Medicare rules for coverage have been 
met. Therefore, we decided that the Plan has to pay for procedure codes 15002, 15004, and 97606 billed for 
date of service June 9, 2023.  
 
We also decided that the Plan does not have to pay for procedure codes 15100, 15120, 28005, 15275, 
15271, and 15272. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered.  
 
In this case, assistant surgery services for Current Procedural Terminology codes 15100, 15120, 28005, 15275, 
15271, and 15272 were billed The Medicare Fee Schedule Database contains a surgical indicator of 1 for these 
services. This means that Medicare has determined that an assistant surgeon is not medically necessary and will 
not be paid. Based upon this information, we find that Medicare coverage criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 15100, 15120, 28005, 15275, 
15271, and 15272 billed for date of service June 9, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on August 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 15, 2021. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on August 15, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional routine transportation trips. 
 
You asked the Plan to pre-approve the 10 additional trips. The Plan denied your request. The Plan says the 
record shows you have used 8 one-way trips. Per the plan, you are allowed 10 one-way trips which leaves 2 
trips available. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 10 
additional trips. Based on this information, we decided that you have exhausted the Plan maximum benefit for 
coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 10 
additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection of an anesthetic or steroid into the 
genicular nerve (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the request is medically necessary. 
The Plan denied your request. The Plan says the service 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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental at this time and it is the subject of ongoing clinical 
trials. Therefore, 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the injection of an anesthetic or steroid into the genicular nerve (64454).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve revita. 
 
You asked the Plan to pre-approve revita. You say that you are requesting reconsideration for the denied claim. 
The Plan denied your request. The Plan says that it is never covered by Medicare for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 revita. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical documentation supports that this patient has undergone standard wound care for 
greater than 1 month. Revita is an amniotic membrane allograft wound covering. The medical documentation 
supports that this enrollee is at risk for further amputation due to the fact that they have peripheral vascular 
disease (PVD), diabetes, and prior ulceration with need for amputation of hallux. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revita have been met. Therefore, we decided that the Plan has to pre-approve 
revita.  
 
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 pre-approve optimizer smart system device. 
 
You asked the Plan to pre-approve optimizer smart system device. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says this is experimental, 
investigational or unproven services. 
 
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 optimizer smart system device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found it remains the subject of multiple studies examining long-term efficacy, as 
well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically 
rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, it would not consider to be medically 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 optimizer smart system device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve optimizer smart system device.
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 the enrollee currently meets LTACH 
admission criteria under CMS guidelines. The Plan denied your request. The Plan says the LTACH services 
requested do not meet the requirements for approval.  
 
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 services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the Plan. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurology care to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve neurology care. You say that you have not gotten help from the Plan's 
network. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and you can 
be treated within the Plan network. 
 
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 
neurology care to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes (A5500) and inserts (A5512) 
for the enrollee.

You asked the Plan to pre-approve diabetic shoes and inserts. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says that your request 
in this case does not meet Medicare criteria for coverage. Maximus overturned the Plan's denial 
based on medical necessity. The Plan requested a reopening and stated that this request was not 
denied for medical necessity but because the certification was not signed by a Certifying 
Physician. The Plan is correct in this case.

The Plan must follow Medicare rules. Medicare rules say that the Certifying Physician is defined as 
a doctor of medicine (M.D.) or a doctor of osteopathy (D.O.) who is responsible for diagnosing and 
treating the beneficiary's diabetic systemic condition through a comprehensive plan of care. The 
certifying physician may not be a podiatrist or clinical nurse specialist. Consequent to the M.D. 
or D.O. restriction, a nurse practitioner (NP) and a physician assistant (PA) may not serve in the 
role of the certifying physician, unless practicing "incident to" the supervising physician's 
authority. The rules also state that the certifying physician has certified that certain criteria 
are met and that he/she is treating the beneficiary under a comprehensive plan of care for his/her 
diabetes and that the beneficiary needs diabetic shoes. For claims with dates of service on or 
after 01/01/2011, the certifying physician must:
-Have an in-person visit with the beneficiary during which diabetes management is addressed within 
6 months prior to delivery of the shoes/inserts; and
-Sign the certification statement (refer to the Policy Specific Documentation Requirements section 
below) on or after the date of the in-person visit and within 3 months prior to delivery of the 
shoes/inserts.

We looked at the file and Medicare rules. The file indicates the certification was signed by a 
nurse practitioner and not an MD or DO. Based on this information, we decided that Medicare rules 
for coverage of diabetic shoes and inserts have not been met. Therefore, we decided that the Plan 
does not have to pre-approve diabetic shoes (A5500) and inserts (A5512) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that you are a perfect candidate for this procedure. The 
Plan denied your request. The Plan says there is a non-vertebrogenic source that could account for your pain. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no magnetic resonance imaging (MRI) showing only Modic changes without facet 
degenerative joint disease or stenosis. The cause of the enrollee's pain is not clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.