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

 
We decided that the Plan does not have to pay for inpatient post stabilization care provided on 11:18 AM on 
April 28, 2020, through April 29, 2020 with an out-of-network provider. 
 
You asked the Plan to pay for post stabilization care. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized 
by 11:17 a.m. on 4/28/2020 and subsequent care was post stabilization care and was not approved in 
compliance with the health plan?s authorization procedures. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization care. Our reviewer says 
that the service does not meet criteria for post stabilization care. Our physician reviewer found that you failed 
to notify the Plan in timely fashion after the patient was deemed stable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post stabilization care have not been met. Specifically, you did not notify the 
Plan the patient was deemed stable and did not receive authorization to continue care. Therefore, we decided 
that the Plan does not have to pay for inpatient post stabilization care provided on 11:18 AM on April 28, 2020, 
through April 29, 2020 with an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by Albuquerque 
Ambulance Service on July 15, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 15, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by Albuquerque 
Ambulance Service on July 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on April 21, 2020. 
 
You asked the Plan to pay for foot orthotics. You say that you have pain when you walk. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on April 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine foot care provided on May 7, 2020. 
 
You asked the Plan to pay for routine foot care. You say that you are appealing. The Plan denied your request. 
The Plan says the denial of payment for these services is correct, because authorization was not obtained, and 
these services are not covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of 
routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for routine foot 
care provided on May 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home 
use (D9630) provided on July 27, 2020. 
 
You asked the Plan to pay for the drugs or medicaments dispensed in the office for home use. You say that you 
do not agree with the charges and would like to be reimbursed. The Plan denied your request. The Plan says the 
service requested is not covered. 
 
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 pay for the drugs 
or medicaments dispensed in the office for home use (D9630) provided on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient consultation rendered on May 2, 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 procedure code 99255 is not payable. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes.  
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 99255. This code 
has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not 
have to pay for the inpatient consultation rendered on May 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient surgery you had on August 
19, 2020, and the outpatient observation stay you received from August 19, 2020, to August 20, 2020. 
 
You asked the Plan to waive the copayments for the outpatient surgery and the observation stay. You say that 
you shouldn't have to pay these copayments because you had to return to the ER later due to bleeding. The Plan 
denied your request. The Plan says you were charged these copayments 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 $125 
copayment for outpatient hospital observation services and a $125 copayment for outpatient surgery.  
 
You have been asked to pay a $125 copayment for the outpatient surgery and a $125 copayment for the 
observation stay. These copayments apply regardless of the fact that you had to return to the hospital. 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 copayments for the outpatient surgery you had on August 19, 2020, and the 
outpatient observation stay you received from August 19, 2020, to August 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G Orthotic device (L8702). You say that the requested 
MyoPro Motion G Orthotic device (L8702) is medically necessary. The Plan denied your request. The Plan 
says the requested MyoPro Motion G Orthotic device (L8702) 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 MyoPro Motion G Orthotic device 
(L8702). Our reviewer says that the requested MyoPro Motion G Orthotic device (L8702) is not medically 
necessary. Our physician reviewer found the enrollee is with weakness of the left upper extremity following 
multiple right hemispheric ischemic strokes. The clinical records in the case file include a History and Physical 
Exam Review, OT notes dated 3/12/20, 5/27/20, and 6/3/20, a progress note for eye pain dated 1/28/20, and an 
ED note dated 7/15/17.  
 
The documentation is insufficient to demonstrate that the requested MyoPro Motion G Orthotic device is 
medically reasonable and necessary for the enrollee in this case. 
 
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 MyoPro Motion G Orthotic device (L8702) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device (L8702).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of one oral bisphosphonate (e.g., alendronate, ibandronate, risedronate) AND 
Zoledronic acid is required before alternatives like Prolia can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia not 
medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs or any 
reason why they would be unsafe or ineffective for this 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete dental x-rays rendered on July 14, 2020. 
 
You asked the Plan to pay for these services. You say that the services are a financial hardship. The Plan 
denied your request. The Plan says the services are not covered. 
 
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 pay for the 
complete dental x-rays rendered on July 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 10, 2020 by an out 
of network (OON) provider. 
 
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 services were rendered by an out-of-network provider without prior authorization. 
 
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 has network providers 
available who can provide 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 the medical services provided on August 10, 2020 
by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled care and aide visits. 
 
You asked the Plan to pre-approve home health services. You say that you feel you need a nurse to help with 
your condition and physical therapy to help you get stronger. The Plan denied your request. The Plan says the 
denial of authorization for home health care is correct. 
 
 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. Home health aide services may be covered only if there is a need for qualifying 
skilled services. 
 
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 home health services. Our reviewer 
says that you do not meet the Medicare criteria for the requested home health services. Our physician reviewer 
found the records do not show that skilled nursing and/or skilled therapy services are required to effectively 
provide treatment, care, and/or services in order to improve your condition, or to establish/perform a 
maintenance program to maintain your present condition or prevent deterioration. The services you are 
requesting do not meet the definition of home health aide services. Home health aide services are not 
reasonable and necessary to the treatment of your condition by the skilled professional staff. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled care and aide visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that clinical research has shown the safety 
and efficacy of the device. The Plan denied your request. The Plan says the service is considered experimental, 
and not generally accepted for the proposed use. 
 
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 the requested services. Our physician 
reviewer found that the enrollee has a history of COPD, diabetes, hyperlipidemia, hypertension, coronary artery 
disease, and congestive heart failure with preserved left ventricle ejection fraction, requiring hospital 
admission. In this circumstance, therapy change based on data obtained from a CardioMEMS device has been 
demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to 
standard medical therapy. Concerns have been raised about potential bias in this trial calling into question the 
results. The efficacy of the CardioMEMS device is uncertain at this time according to leading authorities, and 
not recommended in current guidelines for the treatment of heart failure. Therefore the device is still 
considered experimental or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99285) on December 28, 
2019. 
 
You asked the Plan to pay for an emergency department visit. You say that the Plan should review their denial 
to complete processing of this claim for payment. The Plan denied your request. The Plan says rules for 
payment have not been met. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an emergency department visit (99285) on December 28, 
2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on August 22, 
2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges 
because you feel that the physician did not do a thorough treatment. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 
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 emergency care provided on 
August 22, 2020.  
 
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit 
MAXIMUS to make a decision on this type of complaint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve any remaining amount above the $1,000 maximum for 
the dental services. 
 
You asked the Plan to pre-approve any remaining amount above the $1,000 maximum for the dental services. 
You say that all of your teeth are up inside your gums. You say that you have multiple health issues, including 
heart problems and chronic obstructive pulmonary disorder (COPD). You say that you have been advised that it 
would not be safe for you to have this procedure done in a typical office setting. You also say that you are 
afraid you are going to turn septic and die from this. The Plan denied your request. The Plan says there is a 
maximum allowance of $1,000 for covered dental services. The Plan says that this benefit has been reached. 
The Plan also says that the outpatient hospital stay is not listed as a covered dental service. 
 
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 maximum benefit of $1,000 has 
been reached. The record shows that the Plan approved the requested dental services up to the $1,000 
maximum benefit. The Evidence of Coverage clearly states that any amount over the maximum benefit is your 
 
 
responsibility. Therefore, we decided that the Plan does not have to pre-approve any remaining amount above 
the $1,000 maximum for the dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blood pressure monitor. 
 
You asked the Plan to pre-approve a blood pressure monitor. You say that the equipment is required and more 
than the $40.00 affiliate account amount. The Plan denied your request. The Plan says the equipment is not 
covered by the patient's policy or Medicare. There is an available resource for it can be purchased through an 
OTC affiliate account ($40.00). 
 
The Plan must follow Medicare rules. Medicare rules say that home blood pressure monitors are considered 
home dialysis supplies and are only covered for enrollees on home dialysis. The records do not show you are 
on home dialysis.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a blood pressure monitor have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a blood pressure monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is 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 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for recurrent seizures and left sided weakness. Medical conditions are stable. There are no medical 
needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that this patient 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 IRF admission and services.