Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexamethasone. 
 
You asked the Plan to pre-approve Dexamethasone. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dexamethasone.  
 Benefits for Dexamethasone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission to be 
provided by a network facility. 
 
 
 
 You asked the Plan to pre-approve the SNF admission. You say that the enrollee has shown signs of recovery 
during the hospital stay but he does require assistance in order to continue to make progress. The Plan denied 
your request. The Plan says authorization denied because the SNF admission is not medically necessary and 
that the enrollee's needs are mainly custodial in nature that can be adequately addressed with intermittent 
skilled services and daily caregiver support. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found there are identifiable skilled nursing 
service needs which require skilled nursing services, including the specialized skill, knowledge and judgment 
of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment. There are no identifiable skilled therapy service needs which require skilled therapy services, 
including the specialized skill, knowledge and judgment of a qualified therapist required to safely and 
effectively provide medically necessary and reasonable treatment. The enrollee does not require skilled nursing 
or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or 
intensity of service criteria to 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission to be provided by a network facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a retainer crown (D6740) and pontic (porcelain
ceramic) (D6245).
You asked the Plan to provide coverage these dental services. You say that these dental services should be
covered by the Plan. The Plan denied your request. The Plan says dental codes and services that are not listed
are not covered. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus
did not apply the correct contract coverage.
The Plan is correct in this case. Medicare does not cover dental services. 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 and are not among those codes listed as covered in the Plan contract agreement.
Therefore, we decided that the Plan does not have to pre-approve a retainer crown (D6740) and pontic
(porcelain ceramic) (D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01936) provided to the enrollee on
February 25, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for a
lack of claim information in the file. The Plan requested a reopen and provided additional information
regarding its denial. The Plan states that according to the Centers for Medicare and Medicaid Services (CMS)
Billing and Coding: Monitored Anesthesia Care article A57361, there is a specific set of covered diagnosis
codes that are required to be reported as the primary diagnosis code for code 01936. The records show the
billed diagnosis code, S3210XA, is not listed on the covered diagnosis code list approved by Medicare. This
guidance also states all those not listed under the ICD-10 codes that support medical necessity of this policy, is
not covered.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, the claim
submitted cannot be paid as billed due to an error with the diagnosis codes. Medicare rules for coverage of
these services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia
services (01936) provided to the enrollee on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $50 copayment charged for an urgent care visit provided
on August 18, 2021.
You asked the Plan to waive this copayment. You say that this was a COVID-19 test which you believed would
be no charge. The Plan denied your request. The Plan says that the cost sharing applied correctly as you were
being billed for a new patient exam and not solely the COVID-19 test. Maximus overturned the Plans denial for
a lack of information in the case file to show what other services were provided during this visit. The Plan
requested a reopen and provided the required medical records.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you must pay $50 copayment for urgent care facility services.
The medial records show you reported to the urgent care facility due to possible exposure to COVID-19. You
were without any symptoms that required treatment related to your exposure. The exam continued to include a
new patient exam and review of all systems for any possible issues beyond virus exposure.
Medicare and the Plan are only waiving copayments for COVID-19 tests provided due to treatment for the
virus confirmed by a positive COVID-19 test. You reported to urgent care due to exposure only, without
symptoms and you were provided both the COVID-19 test and a new patient exam for all systems. You have
been asked to pay the correct copayment 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 $50 copayment charged for an urgent care visit provided on August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair with upgraded 
electronics. 
 
You asked the Plan to pre-approve a replacement power wheelchair with upgraded electronics. You say that the 
items are necessary. The Plan denied your request. The Plan says the enrollee has not had their current device 
for 5 years. Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that that Medicare pays for the least expensive option 
of repair vs. replacement of durable medical equipment (DME). Replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a replacement power wheelchair with upgraded electronics have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a replacement power wheelchair with upgraded electronics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system. 
 
You asked the Plan to pre-approve a CardioMEMS system. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 a CardioMEMS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at this time the CardioMEMS system would not be considered medically appropriate 
and necessary in this enrollees clinical management. 
 
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 CardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system.
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 enrollee meets the criteria for IRF. The Plan 
denied your request. The Plan says authorization denied because IRF is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as skilled nursing facility (SNF). 
 
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 based on the documentation provided, the enrollee does not require the intensity 
of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. The enrollees care needs can be met at a lower level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the item is necessary. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed (E0265, E0266, 
E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a total electric hospital bed have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a total electric hospital bed.
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 the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or 
occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to provide coverage for osseous surgery for tooth #'s 6, 7 and 8.
You asked the Plan to provide coverage for these services. You say that these services are necessary for the
enrollee. You say that the enrollee had osseous surgery in the upper right quadrant in 2017 and the pockets
were root planed. The Plan denied your request. The Plan says that there is no history of periodontal scaling or
root planing in the enrollee's history. Maximus overturned the Plans denial stating these services were
demonstrated to be necessary based on the dental records. The Plan requested a reopen and provided additional
information. The Plan stated that it has been confirmed there is no history of periodontal scaling, or root
planing. The Plan states that the Maximus reviewer actually agreed with the Plan that a more appropriate
treatment would be crown elongation where there is adequate root length and adequate bone support. The Plan
further states that maintenance procedures performed in the past does not qualify as periodontal treatment.
The Plan is correct in this case. 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 osseous surgery was not
available for coverage at the time it was requested.
Therefore, we decided that the Plan does not have to provide coverage for osseous surgery for tooth #'s 6, 7
and 8 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 home health skilled nursing visits and 8 home health 
physical therapy visits. 
 
You asked the Plan to pre-approve 2 home health skilled nursing visits and 8 home health physical therapy 
visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 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. 
 
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 2 home health skilled nursing visits and 
8 home health physical therapy visits. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the review has determined that the records do not show that skilled nursing services 
are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, 
or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to 
maintain the enrollee's level of function and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 home health skilled nursing visits and 8 home health physical therapy visits 
have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 home health skilled 
nursing visits and 8 home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve atrial fibrillation ablation. 
 
You asked the Plan to pre-approve atrial fibrillation ablation. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 atrial fibrillation ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on current guidelines as well as the records provided, catheter ablation of atrial 
fibrillation is not considered to be medically necessary in 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 atrial fibrillation ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve atrial fibrillation ablation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided the Plan does not have to provide coverage for out of network physical therapy.
You asked the Plan to pay for out of network providers. You say that You asked the Plan to pre-approve the
physical therapy visits. You say that the contract provider is 17 to 21 miles away and three visits a week would
not be manageable. The Plan denied your request. The Plan says that the 17-mile distance is considered
reasonable by Medicare criteria. Maximus overturned the Plans denial stating it has confirmed there are not
providers in network that are a closer distance to your home. The Plan requested a reopen and provided
additional information. The Plan confirmed that you are requesting a provider 5 miles from your residence
versus an in-network provider 17 miles from your residence. Your primary care provider dictates which
providers you are to use in each treatment group. The use of providers is not decided based on the distance
from your home.
The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network
providers. The contract with the Plan says that except for emergencies, enrollees must use providers within
their designated group who are in network.
The provider in this case is not a network provider with the Plan. It has been determined that Maximus
mis-spoke in stating there were no in network providers available who could provide this treatment. The Plan is
also correct in that Medicare allows the Plans to determine a network proximity of between 30 to 50 miles to
travel depending on the region of the country the service area covers. This means the 17 to 21 miles the in-network
provider is from your home is well within the limit Medicare allows Plans to require enrollees to
travel. The Plan has network providers available who could have provided the therapy services at issue in this
appeal. Therefore, we decided that the Plan does not have to provide coverage for out of network physical
therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for out of network services.
You asked the Plan to provide coverage for out of network surgery. You say that this surgery is medically
necessary. The Plan denied your request. The Plan says this surgery is available in network. Maximus
overturned the Plans denial stating it was unclear whether it was the facility or the provider that was not in
network. The Plan requested a reopen and confirmed that the enrollee initiated the contact with the out of
network facility. It was also confirmed the enrollee had not been treated previously by this facility. The
enrollee also was not in the midst of treatment with this facility.
The Plan is correct in this case. 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 provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the surgery at issue in this appeal. Therefore, we decided that the Plan does not have to
provide coverage for out of network surgery for the enrollee.