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

 
We decided that the Plan does not have to pay for the resin-based composites provided on August 5, 2020. 
 
You asked the Plan to pay for the resin-based composites. You say that these services were provided by a new 
dentist, and you were not aware they would not be covered. The Plan denied your request. The Plan says you 
have exhausted your $200 comprehensive dental allowance. 
 
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 Plan offers a $200 allowance for 
fillings and simple tooth extractions every year. The record shows that you met the annual allowance on 
August 5, 2020 and your annual allowance has been exhausted. Therefore, we decided that the Plan does not 
have to pay for the resin-based composites provided on August 5, 2020.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 not shown to require, or to be able to perform, fifteen hours per week 
of rehabilitative services with regular physician evaluation.  The enrollees care needs can be met 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 waive the copayment for a specialist office visit provided by a 
participating provider on February 7, 2019. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you thought you would be 
saving money. You say that you didn't realize this would be considered a specialist. The Plan denied your 
request. The Plan says the correct copayment has been applied. 
 
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 $50 
copayment for physician/practitioner services/in-network/specialist.  
 
You have been asked to pay a $50 copayment for a specialist office visit. A nurse practitioner is considered a 
specialist; therefore, the correct copayment has been applied. A specialist office visit falls within the 
physician/practitioner services/in-network/specialist 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 a specialist office visit provided by a participating provider on February 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe LTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee needs close supervision for strengthening with physical and occupational therapies.The Plan denied your request. The Plan says rules for LTACH care have not been met.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 that the enrollee appears to be stabilizing, but requires additional short term acute care services to help further stabilize the enrollee which can safely be completed in the current facility and are likely to not exceed an additional 24 days. The enrollee does not require services in the LTACH that are not already available at the current facility. There are no services at the LTACH that are not already available and covered at the current 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvethe LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0429) received on March 2, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that you were not given your right to select a medical facility of your choice and therefore should not be liable for the copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 $225 copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $225 for these services. 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 ambulance services (A0429) received on March 2, 2020. 

Your complaint about not being permitted to select a medical facility to which to be transported is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 9, 2020 to January 15, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that you were admitted because you could not walk or stand. You assumed since you were in no condition to do so that the hospital would take care of getting the authorization. The Plan denied your request. The Plan says that the inpatient hospital services are not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the enrollee presented to the ER on 1/9/2020 after 2 falls at home. The evaluation revealed orthostatic blood pressure changes; CT of the head was without any acute process, CT maxillofacial revealed non-displaced nasal fractures and the CXR revealed bilateral interstitial changes. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 9, 2020 to January 15, 2020. 

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on August 6, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that the services were necessary. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $200 copayment for ambulance services. 

You have been asked to pay a $200 copayment for ambulance services. Ambulance services fall within the ambulance services 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 ambulance services provided on August 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special knee braces (CPT Code L1831 X2) to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the knee braces. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the knee braces can be approved for a participating 
provider. The Plan states that the requesting provider does not participate with the member's Plan and even 
though the provider states that they are in the process of contracting, they are not contracted at this time. 
 
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 
special knee braces (CPT Code L1831 X2) to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic shoes and inserts provided on May 8, 2020. 
 
You asked the Plan to pay for the diabetic shoes and inserts. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says proof of delivery and medical necessity documentation was requested 
but not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The required documentation was not 
submitted. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the diabetic shoes and inserts 
provided on May 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery for Hoyer Lift. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a backup battery for Hoyer Lift.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to waive the copayments charged for podiatry services provided from
July 11, 2019 to September 4, 2019.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is right. The Plan
denied your request. The Plan says this cost share was charged based on the Plan contract agreement. Maximus
overturned the Plans denial because a 2019 Plan contract had not been provided for review. The Plan requested
a reopen and provided a copy of the 2019 Plan contract.
The Plan is correct in this case. 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 $45 copayment for podiatry services. 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 cost share
charged for physician services provided from July 11, 2019 to September 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the maxillofacial 
area without contrast (70486). 
 
You asked the Plan to pre-approve this service. You say that a CT scan of the maxillofacial area is medically 
necessary for the enrollee. The Plan denied your request. The Plan says that a CT scan of the maxillofacial area 
is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 this service. Our reviewer says that a 
CT scan is not medically necessary. Our physician reviewer found that the enrollee has been evaluated by an 
ear, nose, and throat (ENT) specialist and underwent nasopharyngeal laryngoscopy. She is presently on medical 
therapy with Zithromax and Singular. She has received four weeks of medical treatment. The 2011 University 
of Michigan Health System guidelines recommend that a sinus computed tomography (CT) scan be performed 
while the patient is symptomatic. If symptoms of rhinosinusitis persist for more than three weeks despite 
antibiotics or recur more than three times per year. Because CT scans provide much better definition, plain 
sinus radiography series are not recommended. CT imaging is indicated in patients who have been treated 
repeatedly with antibiotics and other medications for presumed sinusitis, with persistent complaints 
posttreatment, but no clinical evidence of sinusitis, to confirm that the problem is indeed not due to sinonasal 
pathology and thereby avoid continued inappropriate antibiotic administration. Computed tomography imaging 
is not indicated for clinically diagnosed uncomplicated acute sinusitis; however, it is indicated for recurrent 
acute and chronic sinusitis and patients with cerebrospinal fluid (CSF) rhinorrhea (suspected or confirmed, 
spontaneous or iatrogenic). The review has determined that the requested CT Scan is not medically reasonable 
and necessary. The enrollee has only received four weeks of medical therapy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the maxillofacial area without contrast (70486).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal maintenance (D4910). 
 
You asked the Plan to pre-approve the periodontal maintenance. You say that you spoke with a plan 
representative and were told this service is covered. The Plan denied your request. The Plan says this service is 
not a covered benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
periodontal maintenance (D4910).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve abdominoplasty with a panniculectomy (15847) and 
excision, excessive skin and subcutaneous tissue (includes lipectomy) (15830). 
 
You asked the Plan to pre-approve abdominoplasty and panniculectomy. You say that you are appealing for 
procedure codes 15847 and 15830 that was denied because it was missing some photos. The Plan denied your 
request. The Plan says this procedure is cosmetic in nature and is not considered medically necessary and. 
 
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 abdominoplasty and panniculectomy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is a 49-year-old female with a mildly overhanging lower 
abdominal pannus that is stated to cause functional impairment.  However, there has not been sufficient 
documentation of any conservative management attempted.  The photographs are supportive of a relatively 
small lower abdominal pannus. The procedure should be one that meets, but does not exceed, the patient's 
medical need.  Thus, without clear documentation of failed conservative management, the requested procedures 
could exceed the patient's needs.  Therefore, the procedures do not satisfy Medicare medically necessary 
criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of abdominoplasty and panniculectomy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve abdominoplasty with a panniculectomy (15847) and excision, 
excessive skin and subcutaneous tissue (includes lipectomy) (15830).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 29, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on May 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darbepoetin-alfa. 
 
You asked the Plan to pre-approve Darbepoetin-alfa. The Plan denied your request. The Plan says the drug is 
not supported if the enrollee is not being treated with chemotherapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Darbepoetin-alfa. Our physician 
reviewer found that this request is for the treatment of symptomatic anemia due to stage III chronic renal 
disease and chronic disease.  The enrollee has elevated ferritin, creatinine of 1.58 and eGFR of 41. There is no 
noted history of transfusion of red blood cells. The requested use is FDA approved and indicated for the 
treatment of anemia due to chronic kidney disease, including those on dialysis. The records show the enrollee's 
blood pressure is noted as 149/65. One of the FDA contraindications is uncontrolled hypertension. Therefore, 
the documentation does not indicate that the drug is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darbepoetin-alfa have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Darbepoetin-alfa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330), periodic oral 
evaluation (D0120), prophylaxis (D1110), bitewings (D0274), and topical application of fluoride varnish 
(D1206) provided on July 29, 2020 by an OON provider. 
 
You asked the Plan to pay for the oral hygiene instructions, periodic oral evaluation, prophylaxis, bitewings, 
and topical application of fluoride varnish. You say that you are unable to find a list of in-network providers in 
your area. You also say that when this provider checked your coverage, they told you that you were covered. 
The Plan denied your request. The Plan says these services were rendered by an OON provider, and paid 
accordingly to your plan benefits. The Plan also says that oral hygiene instructions are not a covered benefit 
under your dental plan. 
 
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, oral hygiene instructions are not 
among those covered under this benefit. The contract also says that you are responsible for the difference 
between the billed amount and allowed amount for services received OON.  

Therefore, we decided that the Plan does not have to pay for the oral hygiene instructions (D1330), periodic 
oral evaluation (D0120), prophylaxis (D1110), bitewings (D0274), and topical application of fluoride varnish 
(D1206) provided on July 29, 2020 by an OON provider.