Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiology evaluation with an out-of-network provider.
You asked the Plan to pre-approve the cardiology evaluation. You say that the Plan's preferred provider is too far from your home. The Plan denied your request. The Plan says the preferred provider is within a reasonable distance where services can be provided.
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 doctor is not a network provider with the Plan. 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 cardiology evaluation. Our reviewer says that you do not have any documented unique condition that would not be able to be effectively managed by and in-Network provider. Our physician reviewer found you have a clinically stable cardiovascular condition and it would be safe to transfer your care to an in-Network provider. 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 cardiology evaluation have not been met. 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 the cardiology evaluation. Therefore, we decided that the Plan does not have to pre-approve a cardiology evaluation with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve brachytherapy radiation therapy.
You asked the Plan to pre-approve brachytherapy. You say that you are appealing. The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because peer-reviewed medical literature is insufficient to support the long-term efficacy and safety of routine use of brachytherapy.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 brachytherapy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found brachytherapy should be used when surgical removal of a tumor is not an option. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of brachytherapy have been met. Therefore, we decided that the Plan has to pre-approve brachytherapy radiation therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pontic and retainer crowns for a fixed bridge for 
tooth #'s 3 to 5. 
 
You asked the Plan to pre-approve the pontic and retainer crowns. You say that the radiographs indicate decay 
under the proximal margins of tooth #3 and #5 that both need to be replaced and tooth #4 is non restorable. 
You say that the denial is inconsistent with the needs of the patient and the request should be reconsidered. The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
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. The Plan covers the pontic and 
retainer crowns when the services are medically necessary and reasonable.  
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the pontic and retainer crowns. Our 
physician reviewer found that there is a missing tooth on the opposing side of the arch that would be amenable 
to replacement along with #4 on a removable appliance. Our reviewer says that there is no documented need 
for a fixed appliance over a removable one. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontic and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the pontic and retainer crowns for a fixed bridge for tooth #'s 3 to 5.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RFA, nerves innervating the SI joint, with image 
guidance (ie, fluoroscopy or computed tomography) (CPT code 64625), for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services is considered experimental and investigational. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Centers for Medicare & Medicaid Services (CMS) considers RFA of the lateral sacral branches 
experimental due to the wide variation in efficacy reported in the literature. Therefore, the request is deemed 
not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve RFA, nerves innervating the SI joint, with image guidance (ie, fluoroscopy or computed 
tomography) (CPT code 64625), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the arthroscopy, knee, surgical; debridement/shaving of 
articular cartilage (chondroplasty) (CPT code 29877) and arthroscopy, knee, surgical; with meniscectomy 
(medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage 
(chondroplasty), same or separate compartment(s), when performed (CPT code 29881), for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the enrollee has a left knee medial meniscus tear 
with over three (3) months of sharp burning discomfort in their knee, ten (10) weeks of therapy produced 
limited improvement, has medical line tenderness, positive McMurray test, and positive full knee flexion test. 
The Plan denied your request. The Plan says the services are not 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. 
  Our physician reviewer found detailed documentation is not evident regarding significantly impairing 
pathology on the noted magnetic resonance imaging (MRI). The subjective complaints on exam appear to be 
relatively mild in nature. Locking, giving way and/or other significant mechanical issues are not evident. The 
proposed procedures would not typically be supported in this overall scenario. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. Therefore, the request for the services is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) 
(CPT code 29877) and arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any 
meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate 
compartment(s), when performed (CPT code 29881), for the enrollee.
Appeal type: ER
Decision: Favorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided to the enrollee
from February 18, 2020 to February 19, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that this claim should be paid. The Plan
denied your request. The Plan says Medicare criteria for inpatient care were not met. Maximus overturned the
Plans denial due to a lack of medical records in the file. The Plan requested a reopen and provided the required
medical records.
Our Medical Director reviewed the case file and the reopen request. The medical records show the enrollee
presented to the hospital on February 18, 2019 with generalized illness; the enrollee was "slower than normal"
and was weaker. She had no medical complaints. The physical examination was unremarkable. Laboratory
studies did not show significant abnormalities. The EKG and a CT scan of the head revealed no evidence of
acute pathology. The enrollee was diagnosed with acute toxic metabolic encephalopathy, and questionable
Lewy body dementia. The treatment plan was to discharge the enrollee "in the next 24 to 48 hours after seen by
neurology." The neurologist recommended medication changes. It was felt that the enrollee would benefit from
care in a skilled nursing facility, an Alzheimer's unit if needed. The enrollee was discharged on February 21,
2020.
Based on the medical records provided, the documentation does not support that inpatient services were
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 acute inpatient
hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute
inpatient hospital care provided to the enrollee from February 18, 2020 to February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the Hepatologist visit (99215). You say that the member has been a patient of your office since 2019 and the only other place available to render the necessary services would require the member to establish care prior to any procedure being ordered. The Plan denied your request. The Plan says the requested services are available in-network.
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 the medical services to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on December 10 to December 
24, 2020. 
 You asked the Plan to pay for home health services. You say that the provider provided the enrollee with 
services as prescribed by the enrollee's physician. 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 home health services provided on December 10 to December 
24, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided the Plan does not have to pay for a denture repair to tooth number 9 provided on June 30, 2020.
You asked the Plan to pay for these dental services. You say that these services should be covered by the Plan.
The Plan denied your request. The Plan says the benefit maximum for dental services was reached for this type
of service. Maximus overturned the Plans denial for insufficient claim information. The Plan requested a
reopen and provided additional information. The Plan states that a corrected claim shows you received payment
for code D6750 (Crown for denture) on tooth numbers 6 and 11 that processed with a $0 responsibility to you.
The Plan states your appeal was partially overturned prior to our original decision and that you are only
responsible to pay for code D6240 for treatment provided for tooth number 9 because you previously met your
benefit maximum for this service on May 17, 2017.
The Plan is correct in this case. Medicare 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 treatment provided to tooth number 9 was
not within the benefit period on the date of service. Therefore, we decided that the Plan does not have to pay
for a denture repair provided to tooth number 9 on June 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 17, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the submitted 
documentation did not contain a signed physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Additionally, the records provided do not contain 
documentation of the ordering physician?s intent that the tests be performed. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on May 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient rehabilitation services provided 
from July 8, 2021, to July 12, 2021. 
 
You asked the Plan to waive the coinsurance for outpatient rehabilitation services. You say that you disagree 
with the out-of-network charges because the facility said they were in-network. 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 45% 
coinsurance for out-of-network outpatient rehabilitation services.  You received outpatient rehabilitation services from an out-of-network provider from July 8, 2021, to July 12, 
2021. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total 
allowed amount is $235.91 and 45% of that is $106.16.  
 
You have been asked to pay the total coinsurance amount of $106.16 for outpatient rehabilitation services. 
Outpatient rehabilitation services fall within the outpatient rehabilitation 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 coinsurance for outpatient rehabilitation services provided from July 8, 2021, to July 
12, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met. The QIC overturned the Plans
denial. The Plan requested a reopen and stated the QIC did not apply the correct criteria.
Our Medical Director reviewed the reopen request and the case file. At issue is coverage for IRF care.
The Physician Reviewer determined that the complexity of the enrollee's nursing, medical and
rehabilitation needs (in particular, the wound care) required an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee required treatment by multiple therapies,
including physical therapy and occupational therapy, and an intensive rehabilitation therapy program. There
was a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an inpatient rehabilitation facility. The health plan has requested a
re-opening, citing an error on the face of the evidence. The plan has stated that it disagrees with our
consultant's determination. The plan argues that the enrollee had not completed the acute hospital course of
treatment prior to dispatch to an IRF for intensive rehabilitation.
The medical records show the enrollee underwent resection with a vascular graft and plastics flap. The postoperative
course was complicated by delirium with agitation, hallucinations, and increased paranoia. The
psychiatric consultation follow-up notes on August 5, 2020 documents that the enrollee was globally
encephalopathic. The Orthopedic Surgery Progress Note: Oncology note dated August 6, 2020 documents that
the enrollee remained delirious, confused, and was having visual/auditory hallucinations. An infectious workup,
delirium precautions, and agitation management were ongoing.
Our Medical Director found that based on the medical records provided, the plan is correct in this case. The
documentation does not support that the enrollee was stable for transfer to an IRF at the time of the request. 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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for advanced life support, non-emergency 
ground transportation (A0426, A0425) rendered on May 14, 2021. 
 
You asked the Plan to waive the copayment for advanced life support, non-emergency ground transportation. 
You say you were told that ambulance transport is part of the whole connected care and the enrollee would not 
be billed separately. You also say that you offered to drive the enrollee, but the provider insisted on the enrollee 
going by ambulance. The Plan denied your request. The Plan says you were charged the correct cost sharing 
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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $275 copayment for ambulance services.  
 The enrollee has been asked to pay $266.78, which is less than the $275 copayment for advanced life support, 
non-emergency ground transportation. Advanced life support, non-emergency ground transportation falls 
within the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct 
amount 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 copayment for 
advanced life support, non-emergency ground transportation (A0426, A0425) rendered on May 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cystourethroscopy (52000) rendered on 
June 25, 2021. 
 
You asked the Plan to waive the copayment for a cystourethroscopy. You say that for the past twenty years you 
have had this procedure done in the provider's office with a $35 copayment. You also say you should not have 
to pay a $375 copayment for the procedure to be done in the hospital due to the provider office being 
remodeled at this time. The Plan denied your request. The Plan says you were charged the correct copayment. 
 
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 $375 
copayment for per visit for in-network outpatient surgery.  
 
You have been asked to pay a $375 copayment for a cystourethroscopy. Cystourethroscopies fall within the 
Outpatient Surgery, including services provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 cystourethroscopy 
(52000) rendered on June 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for hearing aids purchased on July 30, 2020.
You asked the Plan to pay for hearing aids purchased. You say that these hearing aids should be covered by the Plan. The Plan denied your request. The Plan says hearing aids are not covered by the Plan.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. Where you purchased the hearing aids is not a Plan provider. Therefore, we decided that the Plan does not have to pay for to pay for hearing aids purchased on July 30, 2020.