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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for Parkinson's disease and a fall. 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 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 medically necessary. The Plan denied your 
request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to 
a long-term acute care hospital. 
 
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 is a 74-year-old for whom coverage of 
LTACH services is requested. 
 
At issue is whether LTACH services for the enrollee is a covered service under Medicare rules.  LTACHs are 
certified under Medicare as short-term acute care hospitals that have been excluded from the acute care hospital 
inpatient prospective payment system (PPS) in the Social Security Act, Section 1886(d)(1)(B)(iv) and, for 
Medicare payment purposes, are generally defined as having an average inpatient length of stay of greater than 
25 days.  Services in an LTACH must be medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need medical 
care. The services must be able to be furnished safely and effectively only on an inpatient basis. 
 
In this case the enrollee was admitted for elective esophageal stricture that was complicated by septic shock 
from aspiration pneumonia.  The record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied.  The medical record does not indicate that the enrollee requires services that the 
enrollee is not currently receiving but that would be available at the LTACH facility.  The elements of the 
coverage rules 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 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 pay for periodontal scaling and root planing - four or more teeth per 
quadrant (D4341) provided on November 9, 2022. 
 
You asked the Plan to pay for the periodontal scaling and root planing. You say that the probing levels and 
previous radiographs from 2021 and 2022 clearly demonstrate the radiographic areas of bone loss. The Plan 
denied your request. The Plan says per the utilization review guidelines, the clinical requirement for scaling 
and root planning have not been met. 
 
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 the 
periodontal scaling and root planing 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 pay for the periodontal scaling and root planing. Our 
reviewer says that the requested treatment under code D4341 is not medically necessary. Our physician 
reviewer found in this instance there is only one tooth that has any pockets in excess of 4 mm. As there is only 
one tooth that is involved in the upper left quadrant, the code is not applicable.  
 
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 the periodontal scaling and root planing have not been met. Therefore, we 
decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per 
quadrant (D4341) provided on November 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99232, 99233) provided on 
February 22, 2021. 
 
You asked the Plan to pay for subsequent hospital care. You say that you want the Plan to pay for the services. 
The Plan denied your request. The Plan says more than one calendar year from the date of service had passed 
before a claim was filed. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
   
The record shows that a claim for subsequent hospital care was not filed until January 4, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for subsequent hospital care (99232, 99233) provided on February 
22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for imaging services provided to the enrollee on September 20, 2022.
You asked the Plan to pay for these services . You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that this claim was not reported with the required anatomical modifier. The provider needed to bill the anatomic specific modifiers LT (Left side), RT (Right side), and 50 (Bilateral procedure) to designate the area or part of the body on which the procedure is performed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed due to the omission of a required modifier.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on September 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative neurophysiology (95941). 
 
You asked the Plan to pay for the intraoperative neurophysiology . You say that the service should be covered. 
The Plan denied your request. The Plan says you may not balance bill the patient unless you have a written 
agreement to do so prior to the services being performed. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the intraoperative neurophysiology have not been met. Specifically, the record indicates that the 
Plan has paid the Medicare allowed amount for this service. A Medicare provider should accept the Medicare 
allowed amount as payment in full. In this case, the Plan is not responsible for paying the balance that remains after the Medicare allowed payment. Therefore, we decided that the Plan does not have to pay for the 
intraoperative neurophysiology (95941).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
November 5, 2021, to November 12, 2021 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you already paid for 
the inpatient care. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment per day, for days 1 to 5 and a $0 copayment per day, for days 6 to 90 for Medicare-covered 
inpatient hospital stays.  
 
 You have been asked to pay a $350 copayment per day, for days 1 to 5 of the inpatient hospital stay. You have 
been asked to pay a total of $1,750 ($350 copayment x 5 days = $1,750). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the inpatient hospital stay provided from November 5, 2021, to 
November 12, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an 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 requested IRF services are not medically necessary.  
 
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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device (22869). 
 
You asked the Plan to pre-approve a Vertiflex device. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the procedure is denied because there is not enough medical evidence that 
shows the procedure is safe and helpful. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertilfex device is experimental and investigational. There is more research 
needed due to efficacy. 
 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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device (22869).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from January 18, 2022, to February 14, 
2022. 
 You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility care needs  
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from January 18, 2022, to February 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery (20680, 27707, 27870) provided on November 
19, 2021. 
 
You asked the Plan to pay for the surgery. You say that the service should be covered. The Plan denied your 
request. The Plan says the referring provider has been excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that he Office of the Inspector General (OIG) 
maintains a sanction list that identifies those individuals found guilty of fraudulent billing, misrepresentation of credentials, etc. The MA organizations employing or contracting with health providers have a responsibility to 
check the sanction list with each new issuance of the list, as they are prohibited from hiring, continuing to 
employ, or contracting with individuals named on that list. The MA organizations should check the Office of 
the Inspector General (OIG) Web site at http://www.oig.hhs.gov/fraud/exclusions/list of excluded.html for the 
listing of excluded providers and entities. The OIG has a limited exception that permits payment for emergency 
services provided by excluded providers under certain circumstances. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgery have not been met. Therefore, we decided that the Plan does not have to pay for the 
surgery (20680, 27707, 27870) provided on November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services with an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says dental services from an out-of-network provider are not covered by your 
supplemental benefits.  
 
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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental 
services with an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says Keytruda is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that 
Keytruda is not medically necessary. Our physician reviewer found that Keytruda is not FDA approved. There 
is no evidence of progression of disease, high microsatellite instability, mismatch repair deficient, or plans to 
use with lenvantinib. The use of Keytruda is not supported by one of the major drug compendia.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the non-routine eye exam provided on 
January 11, 2023. 
 
You asked the Plan to waive the copayment for the non-routine eye exam. You say that you were supposed to 
have a diabetic retinopathy screening, but a different exam was performed. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or 
condition of the eye.  
 You have been asked to pay a $45 copayment for the non-routine eye exam. This service falls within the vision 
care benefit category. The record shows assessments for non-insulin dependent diabetes mellitus with no 
diabetic retinopathy, mild cataracts, hyperopia with astigmatism and presbyopia, ocular migraines, and 
posterior vitreous detachment which makes the eye exam medical in nature. 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the non-routine eye exam provided on January 11, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve hyperbaric oxygen therapy (HBOT). 
 
You asked the Plan to pre-approve the HBOT. You say that the enrollee is in dire need of the requested 
treatment so that their foot can be saved. The Plan denied your request. The Plan says that the records do not 
indicate that the enrollee has failed 30 days of standard wound therapy with measurements. 
 
The Plan follows Medicare rules. Medicare rules say that the use of HBO therapy is covered as adjunctive 
therapy only after there are no measurable signs of healing for at least 30-days of treatment with standard 
wound therapy and must be used in addition to standard wound care. 
 
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 HBOT. Our reviewer says that the 
requested hyperbaric oxygen therapy (HBOT) is medically necessary. Our physician reviewer found the 
provided documentation indicates the enrollee underwent removal of infected surgical hardware in the ankle in 
April 2023. The enrollee has a history of diabetes mellitus type II and originally underwent ankle surgery for a 
fracture. The reviewer found that the enrollee has been receiving ongoing antibiotics and was recently 
hospitalized on May 24, 2023, for continued infection and drainage of the ankle and surgical site. The 
documentation indicates the enrollee has been receiving ongoing wound care therapy and assessment since 
April 2023 and continues to have no measurable signs of healing. Therefore, the hyperbaric oxygen therapy is 
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 HBOT have been met. Therefore, we decided that the Plan has to pre-
approve hyperbaric oxygen therapy (HBOT).  
 
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.