Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on  
May 22, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the panoramic radiographic 
image provided 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 panoramic radiographic image provided was exhausted on date of service  
February 4, 2021. Specifically, the Plan's contract states that one full mouth or panoramic x-ray is covered 
every five years. You previously received a panoramic x-ray on February 4, 2021, less than five years prior, 
which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for this service. Therefore, 
we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on  
May 22, 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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is not medically neessary.  
 
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, and can be 
provided in a lower level of care. The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in a lower level of care. There is documentation that 
there is 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, but the services required can be provided at a 
lower 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 7, 2023, billed with 
procedure code 29581-59-RT. 
 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 29581 is a column II code to column I code 11042; however, 29581 
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 medical record describes 
debridement performed on right leg and a 3-layer Unna boot compression dressing system applied. When both 
a debridement is performed and an Unna boot is applied, only the debridement may be reimbursed. If only an 
Unna boot is applied and the wound is not debrided, then only the Unna boot application may be eligible for 
reimbursement. In this case, billing both procedures resulted in unbundling.  
 
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 August 7, 2023, billed with procedure code 
29581-59-RT.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the notes do not show that the enrollee's care specifically requires 
the involvement of a doctor in the field of Rehabilitation Medicine; the notes do not show that the enrollee has 
complex care needs that require a coordinated team approach; the notes do not show that the enrollee must 
have an intensive therapy program (3 hours a day, at least 5 days a week) in order to improve self-care 
functioning.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulator (PNS). 
 
You asked the Plan to pre-approve Sprint PNS. You say that this is medically necessary. The Plan denied your 
request. The Plan says this has not been shown to be effective in the medical literature. 
 
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 Sprint PNS. 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/investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Sprint peripheral nerve stimulator (PNS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve large pull-ups (T4523). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve large pull-ups (T4523).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy techniques and the therapeutic exercises 
provided by a chiropractor on February 6, 2023. 
 
You asked the Plan to pay for the manual therapy techniques and the therapeutic exercises. You say that the 
claim should be reprocessed for payment. The Plan denied your request. The Plan says the only covered 
chiropractic service is manual manipulation of the spine. 
 
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 the manual therapy techniques and the therapeutic provided by a chiropractor 
on February 6, 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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee's records do not show that they need to be 
seen by a rehabilitation doctor 3 times per week. The enrollee does 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 the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care, and can be 
provided in a lower level of care.  The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in a lower level of care. There is documentation that 
there is 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, but the services required can be provided at a 
lower 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 an electronic connection (E2311), an expandable 
controller harness (E2313), an expandable controller (E2377), freewheel assembly (K0108), freewheel 
assembly release (K0108 x2), suspensions (K0108 x2), front suspension assembly (K0108), motor mount 
assembly (K0108), and privacy flap (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee requires the wheelchair 
base and all recommended components to meet their mobility, medical, and functional needs in their home. The 
Plan denied your request. The Plan says although there are three approved power options on this wheelchair, 
there is not a medical need to control these power options through a special type of joystick. The Plan also says 
the freewheel assembly, freewheel assembly releases, suspensions, front suspension assembly, motor mount 
assembly, and privacy flap do not primarily serve a medical purpose, and cannot be covered as these are not 
reasonable and necessary per Medicare criteria. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found per Social Security Administration (SSA) 1862 (a)1(A), the enrollee has sufficient 
strength to manage standard power drives. The freewheel assembly (K0108), freewheel assembly release 
(K0108 x2), suspensions (K0108 x2), front suspension assembly (K0108), motor mount assembly (K0108), and 
privacy flap (K0108) do not serve a medical purpose and are for use outside the home for the free wheel 
assembly. The privacy flap is not medically necessary and represents unbundling from the seat assembly. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311), an expandable controller harness (E2313), an 
expandable controller (E2377), freewheel assembly (K0108), freewheel assembly release (K0108 x2), 
suspensions (K0108 x2), front suspension assembly (K0108), motor mount assembly (K0108), and privacy flap 
(K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Mohs micrographic surgery (13121, 17311, 17312) provided 
on August 22, 2023, by an out-of-network (OON) provider.  
   
You asked the Plan to pay for Mohs micrographic surgery with an out-of-network provider. You say that you 
want the Plan to pay for the services. The Plan denied your request. The Plan says the provider is out-of-
network. The services were not referred by a network provider or rendered in a participating facility. The 
services were not urgent or emergent, nor were they approved in advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Mohs micrographic surgery (13121, 17311, 
17312) provided on August 22, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an all-lower extremity prostheses, flex-walk system or
equal (L5981) for the enrollee.

You asked the Plan to pre-approve an all-lower extremity prostheses, flex-walk system or equal. You say that
the enrollee's daily activities require that she do more than simple walking. The enrollee exhibits all necessary
physical needs to successfully utilize a prosthesis as a K3 ambulator. The Plan denied your request. The Plan
says that the enrollee does not meet criteria for the requested prosthetic.

The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plan's denial. The Plan
requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the enrollee's
physician states a K3 foot is medically necessary as the enrollee is a K3 ambulator. However, this is not
consistent with available medical history. The medical records show the enrollee currently uses a wheelchair.

This is not consistent with K3 ambulation. Medicare covers items that meet, but do not exceed, the member's
need. The medical records do not show why the enrollee requires a K3 foot, or why a standard foot would not
meet the enrollee's needs. Therefore, the documentation does not demonstrate that the enrollee is a K3
ambulator.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say the documentation
provided does not support that the enrollee was a K3 ambulator at the time of the appeal. Medicare rules for
coverage of the requested prosthetic equipment have not been met. Therefore, we decided that the Plan does
not have to pre-approve an all-lower extremity prostheses, flex-walk system or equal (L5981) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grab bar. 
 
You asked the Plan to pre-approve a grab bar. You say that you need this item. The Plan denied your request. 
The Plan says this item does not primarily serve a medical purpose.  
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a grab bar.
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 it is unsafe for the enrollee to return home 
independently because they are a continued fall risk and they do not have anyone to ensure they are safe. The 
Plan denied your request. The Plan says the notes do not show that the enrollee's care specifically requires the 
involvement of a doctor in the field of Rehabilitation Medicine; the notes do not show that the enrollee has 
complex care needs that require a coordinated team approach; the notes do not show that the enrollee must 
have an intensive therapy program (3 hours a day, at least 5 days a week) in order to 
improve self-care functioning.   
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that this medication was denied due to benefit 
exclusion. 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. While Ondansetron may be covered by Medicare Part B, this request is not covered because it will not be used as a full therapeutic replacement for intravenous anti-emetic drugs during a 
chemotherapy regimen. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.  
 
Benefits for Ondansetron 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: 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 need IRF care as you live alone and do not have 
the resources to get help. The Plan denied your request. The Plan says you do 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 complexity of your nursing, medical, and rehabilitation can be provided at a 
lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can be provided in a lower 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.