Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says pneumatic compression 
devices are not covered by Medicare for deep vein thrombosis (DVT) prevention. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care visits provided from November 
5, 2021, to November 19, 2021. 
 
You asked the Plan to waive the copayment for wound care visits. You say that there should not be a 
copayment for these services. 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 $250 
copayment for outpatient hospital services. 6 visits x $250 copayment = $1,500, you are being asked to pay the 
lesser copayment amount of $794.71.  
 
You have been asked to pay a $794.71 copayment for wound care visits. This item/service falls within the 
outpatient hospital 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 wound care 
visits provided from November 5, 2021, to November 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 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 you are medically stable and do not need physician's supervision 3 times a week in an 
IRF. There are no nursing needs identified or documented. At the current level of function, you do not need 
intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with a 
multidisciplinary approach in an IRF. While you may benefit from continued physical therapy, and 
occupational therapy, your rehabilitation needs can be safely provided in a lower intensity and alternate 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on July 17, 
2022. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that this service is too costly and 
you cannot afford it. 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 $325 
copayment for ambulance services. 
 
You have been asked to pay a $325 copayment for an ambulance ride. This item/service falls 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 an ambulance ride 
provided on July 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the 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 you have no complex nursing or rehabilitation needs.  
 
 You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you may 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 you 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 the IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the out-of-network annual wellness visit 
provided on June 14, 2022. 
 
You asked the Plan to waive the coinsurance for the out-of-network annual wellness visit. You say that your 
book says there is no charge for a physical and only a $20 copayment for office visits. 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 40% 
coinsurance for annual wellness visit (out-of-network). 
 
You have been asked to pay 40% coinsurance for the out-of-network annual wellness visit. This item/service 
falls within the annual wellness visit (out-of-network) 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.The file shows that the Plan verified the provider is not a network 
provider. Therefore, the 40% out-of-network coinsurance was applied to the wellness visit. Therefore, we decided that the Plan does not have to waive the coinsurance for the out-of-network annual wellness visit 
provided on June 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 foot (L5981) for the enrollee.
You asked the Plan to pre-approve a K3 foot. You say that you disagree with the Plan's denial. The Plan denied
your request. The Plan says the requested item is not medically necessary.
Our Medical director looked at the case file and the reopen request. At issue is coverage for a K3 foot. Our
Medical Director states that the available clinical documentation in the case file does not support that the
enrollee's functional level was 3 or above. Our physician reviewer found the enrollee's condition does not meet
criteria for coverage of a K3 foot.
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 K3 foot have not been met. Therefore, we decided that the Plan does not have
to pre-approve a K3 foot (L5981) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (J3380). 
 
You asked the Plan to pre-approve Entyvio. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Remicade, Inflectra, or Infliximab; and Stelara. 
 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 Entyvio. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed any of the preferred drugs. The reviewer found that there is no indication 
that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the 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 Plans 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 dental 
services on August 2, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on March 14, 2022. 
 
You asked the Plan to pay for the radiology services. You say that the medical records support the services 
billed. The Plan denied your request. The Plan says the patient was on hospice on the date of service in 
question, so either hospice or Original Medicare is responsible for this claim. 
 
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 radiology services provided on March 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 9, 2022, to June 
28, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Medicare rules say for all enrollees receiving 
home health services in 2021 whose services will continue in 2022, the home health agency shall submit an 
NOA with a one-time artificial admission date corresponding to the From date of the first period of 
continuing care in 2022. Based on this information, we decided that Medicare rules for completing the claim 
for home health services have not been met. Specifically, the file shows that a subsequent claim was submitted 
with an admission date of August 7, 2021, which does not match the admission date on the NOA. Therefore, 
we decided that the Plan does not have to pay for the home health services provided from June 9, 2022, to June 
28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 23, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on August 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Foundation One CDx (F1CDx) testing provided on June 
3, 2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the services billed. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the F1CDx testing have been met. 
Complete medical records from the treating physician are needed to determine the medical necessity of why the 
large number of genes were tested or how they will impact the enrollee's care. Therefore, we decided that the 
Plan does not have to pay for the Foundation One CDx (F1CDx) testing provided on June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 30, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support these services. The 
Plan denied your request. The Plan says services can be obtained by an in-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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on June 30, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain tooth #'s 7 and 10 (D6240), and 
retainer crown - porcelain tooth #'s 8 and 9 (D6750). 
 
You asked the Plan to pre-approve the pontic - porcelain tooth #'s 7 and 10 (D6240), and retainer crown - 
porcelain tooth #'s 8 and 9 (D6750). You say that you have been to multiple providers concerning the space in 
the front of your mouth and teeth that have been broken below the gum line. You also say that you need the 
requested services as soon as possible. The Plan denied your request. The Plan says these services are not 
covered under the benefit package. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
pontic - porcelain tooth #'s 7 and 10 (D6240), and retainer crown - porcelain tooth #'s 8 and 9 (D6750).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not medically 
necessary. 
 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 pre-approve 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 You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an immediate maxillary denture (D5130) and an 
immediate mandibular denture (D5140) provided on July 20, 2022. 
 
You asked the Plan to pay more for the dentures. You say that you were told the dentures would be covered at 
100%. The Plan denied your request. The Plan says that your annual dental allowance has been exhausted. 
 
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 record shows your annual dental allowance has been exhausted. You are responsible for any amount above 
the benefit coverage limit. 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 pay more for an immediate maxillary denture 
(D5130) and an immediate mandibular denture (D5140) provided on July 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for surgery services provided to the enrollee on December 9, 2021.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says the records provided
do not support the services billed. Maximus overturned the Plans denial as no medical records were in the case
file. The Plan requested a reopen and provided the medial records submitted to support the claim.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
must furnish to the intermediary or carrier sufficient information to determine whether payment is appropriate.
Based on the medical records provided, there is insufficient information in the record to support the services
billed. Therefore, we decided the Plan does not have to pay for surgery services provided on December 9, 2021.
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 due to the enrollee's medical complexities related to 
their comorbidities, the enrollee is not safe to discharge to any other level of care except inpatient rehab. The 
Plan denied your request. The Plan says an intensive rehabilitation program 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 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 do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While 
the enrollee may benefit from physical and occupational therapy, the enrollee's rehab needs can be safely met 
in an alternate and low intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.