Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 3, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
physicians services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac monitor. 
 
You asked the Plan to pre-approve a cardiac monitor. The Plan denied your request. The Plan says the 
placement of an insertable loop recorder at the time of catheter ablation to determine ablation failure is not 
considered a medically-necessary indications. 
The Plan follows Medicare rules. Medicare rules say that electrocardiographic services are only covered under 
certain medical indications. 
 
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 cardiac monitor. Our physician 
reviewer found that the enrollee has a history of hypertension and paroxysmal atrial fibrillation with 
documented recurrence while on amiodarone. The enrollee is now being scheduled for ablation. In this 
circumstance, standard monitoring for recurrent atrial fibrillation includes electrocardiograms, Holter 
monitoring, and extended external event monitoring. The placement of an implantable loop recorder for the 
purpose of identification of atrial fibrillation post ablation is not supported by the medical records. The records 
do not indicate a failure or contraindication to external monitoring. The routine implantation of loop recorders 
after ablation of atrial fibrillation is also not supported by current guidelines. Therefore, the requested service is 
not considered medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a cardiac monitor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a cardiac monitor.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 pre-approve admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not 
have complex wound care or other ongoing SNF level skilled nursing need. The enrollee's functional level does 
not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist 
to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not 
require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a 
SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a 
skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you are covered for up to 24 one-way trips 
per calendar year. The Plan says that you have used all 24 one-way trips for the 2020 benefit year and 
additional trips will not be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says you have 
no documented trunk or abdominal edema. 
 
The Plan must follow Medicare rules. Medicare rules say a PCD coded used to treat lymphedema not extending 
onto the chest, trunk and/or abdomen will be denied as not reasonable and necessary. 
 
We looked at the file, and Medicare rules. The documentation provided shows that you have tried and failed 
several conservative treatments. However, the records do not indicate that you have abdominal or trunk 
swelling. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interspinous spacer services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network 
provider. 
 
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 
interspinous spacer services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not 
require transfer to the LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the short-term acute care hospital can provide for all of your present inpatient care 
needs and the patient is receiving an appropriate level of care in the present setting. Continued care in the short-
term acute care hospital is appropriate until you are stable to transfer to a lower level of care such as an 
inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing 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-approve admission to a long term acute care hospital.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency room visits provided on 
June 20, 2020 and July 1, 2020. 
 
You asked the Plan to waive the copayments for the emergency room visits. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says the enrollee received emergency care visits on the dates of service at issue 
in this appeal. The Plan says that the correct copayments have applied per the enrollee's contract with the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $120 copayment for Emergency care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received 
emergency care visits on June 20, 2020 and July 1, 2020. The enrollee has been asked to pay a $120 copayment 
for each emergency room visit. The emergency room visits fall within the Emergency care benefit category. 
This means that the enrollee has been asked to pay the correct amounts based on the contract with the Plan. 
This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayments for the emergency room visits provided on 
June 20, 2020 and July 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two level lumbar fusion surgery. 
 
You asked the Plan to pre-approve two level lumbar fusion surgery. You say that the clinical information 
provided supports the need for the requested surgery. The Plan denied your request. The Plan says the medical 
information does not show that there is radiographic or clinical evidence of instability, a symptomatic spinal 
deformity, pseudoarthrosis, or symptomatic compression of neural elements for which disc excision is 
necessary for decompression at each level. The Plan says that the criteria for coverage have not been met. 
 
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 two level lumbar fusion surgery. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee presents with a history of chronic axial low back pain. Functional 
limitations are noted in activities of daily living and work activities. There is imaging evidence of degenerative 
changes, most pronounced at L5/S1, where there was some bulging of disc and osteophytic changes resulting in 
some right neuroforaminal narrowing. There are reported radiographic findings of significant degeneration at 
the L4/5 and L5/S1 levels with loss of alignment in the lower lumbar spine. He has failed to improve with long-
term conservative treatment, including activity modification, medications, physical therapy, and unspecified 
injections. There is no radiographic or clinical evidence of instability. There is no evidence of symptomatic 
spinal deformity. This is not a revision surgery. There is no documentation supporting the medical necessity of 
decompression surgery at either level. Clinical exam findings do not evidence any focal neurologic deficits 
supporting a diagnosis of radiculopathy or correlated with imaging evidence at either the L4/5 or L5/S1 level. 
The enrollee has not met the Medicare coverage criteria for 2-level fusion surgery. Therefore, this request for 
2-level lumbar fusion would not be considered medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of two level lumbar fusion surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve two level lumbar fusion surgery.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the dental implant for tooth #26 provided on February 17, 2020. 
 
You asked the Plan to pay for the implant. You say that you were told this would be covered for reimbursement 
as long as a letter from the dentist was provided on why dentures could not be used. You were never given the 
option to request authorization and would have done so if you knew this was necessary to ensure 
reimbursement. The Plan denied your request. The Plan says that there is no evidence that masticatory function 
would be impaired with the use of a removable denture. As such, this implant is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of both the EOC and the Dental Benefits document (Exhibit B) show 
that implants are covered services under the Plan. Neither document provides any limitation or exclusion which 
would indicate criteria to be met in order to qualify for an implant vs any other type of tooth replacement. It is 
noted in the appeal letter that the Plan was contacting prior to the performance of this service and was not told 
that authorization would be required to confirm the medical necessity of an implant vs alternate tooth 
replacement. Upon appeal, the only documents reviewed were those that the enrollee herself sent. There is no 
evidence that the Plan attempted to obtain full medical records from the treating dentist or x-rays.  
 
Based on the information available, we find that the enrollee had no reasonable expectation that implant 
coverage would be limited by any specific criteria. Without the ability to review the dental records with x-rays, 
Maximus cannot perform an independent review of the medical necessity of this implant. We find that there is 
a lack of support of the Plan's denial rationale in the documentation available. Therefore, we decided that the 
Plan has to pay for the dental implant for tooth #26 provided on February 17, 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: Favorable

 
We decided that the Plan has to waive the $150 copayment charged for an ambulance transport provided on 
December 9, 2019. 
 
You asked the Plan to waive this copayment. You say that you should not have to pay this copayment. The 
Plan denied your request. The Plan says that this copayment is a contractual obligation based on your 2019 
Plan contract agreement.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request. The Plan included the incorrect Plan contract with the case file. 
We requested a 2019 contract which was not submitted prior to the date of this letter. Therefore, we decided 
that the Plan has to waive the $150 copayment charged for an ambulance transport provided on December 9, 
2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on 
March 13, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the Plan's Summary of 
Benefits Handbook clearly indicates that there is a $0 copay for routine dental services. The Plan denied your 
request. The Plan says the cost share was applied correctly according to your plan benefits. The Plan also says 
that cost sharing is a contractual obligation of the Plan and cannot be waived. 
 
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, 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 periodic oral evaluation and prophylaxis provided on March 13, 2020 by an OON 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a 
participating provider on February 25, 2020 to February 28, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you should only have 
to pay for lab work, not a facility fee as well. 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 $325 
copayment for outpatient hospital services/3/in-network/outpatient hospital visit.  
 
You have been asked to pay $129.47 for each date of service, which is less than your copayment amount of 
$325 for outpatient hospital services. The total amount you are being asked to pay is $258.94. When you visit a 
provider, you may be charged an additional fee; therefore, the correct copayment has been applied. When 
services are provided outpatient hospital services falls within the outpatient hospital services/3/in-
network/outpatient hospital visit 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 
outpatient hospital services provided by a participating provider on February 25, 2020 to February 28, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99284), nasal hemorrhage 
control (30903) and electrocardiogram (93010) provided on January 11, 2020. 
 
You asked the Plan to pay for the emergency department visit, nasal hemorrhage control and 
electrocardiogram. You say that you would like reconsideration because the member was seen multiple times 
on the same date. The Plan denied your request. The Plan says CPT code 93010 was denied as a column II code 
to the column I code 30903. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency department visit, nasal hemorrhage control and electrocardiogram have not been 
met. Specifically, the documentation submitted does not support the services billed. The submitted record does 
not support that this provider was involved in the enrollee's care during the billed visit and there is not a 
complete note documenting the services provided. Therefore, we decided that the Plan does not have to pay for 
an emergency department visit (99284), nasal hemorrhage control (30903) and electrocardiogram (93010) 
provided on January 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy assistant service provided on February 
4, 2019. 
 
You asked the Plan to pay for the physical therapy assistant service (G0157). You say that the Plan should pay 
this claim. The Plan denied your request. The Plan says the claim was untimely. 
 
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 the physical therapy service was not filed until March 27, 2020. 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 the physical therapy assistant service provided on February 4, 
2019.