Persius/hicric huggingface dataset:
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 at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus reviewer did not
consider that this enrollee's ability to participate in intensive therapy was described as limited by the sternal
precautions, weakness, and confusion, and that and that the enrollee did not require physician supervision by a
rehabilitation physician at least 3 days per week.
The Plan is correct in that case. 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.
Based on this information, we decided that Medicare rules for coverage of IRF care were not met at the time of
the appeal. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation
facility (IRF) admission and services.
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 needs IRF care. The Plan denied your 
request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements 
for approval. 
 
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 the clinical documentation shows that the enrollee has complex neurological impairments and chronic comorbidities. However, there is no documentation to show that the enrollee would 
tolerate 15hrs of therapy per week (recently discharged from hospice). 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays (71046, R0070, Q0092) provided on August 17, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the x-rays. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the services denied correctly as they were non-emergent 
and prior authorization was not obtained. 
 
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 x-rays (71046, R0070, Q0092) provided on 
August 17, 2022, by an out-of-network (OON) provider.
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 you are unable to walk and need rehabilitation in
order to be able to go home. The Plan denied your request. The Plan says that criteria for admission to the IRF
setting have not been met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of
care.
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 looked at the file and Medicare rules. The file indicates you would be placed on a modified therapy
program. Therefore, you do not meet Medicare rules for IRF care because you are not expected to fully
participate in and to benefit from an intensive rehabilitation therapy program.
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: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services 
 
You asked the Plan to pay for the services. You say that  The Plan denied your request. The Plan says that the 
type of bill was incorrect. 
 
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 has not provided any evidence that they have directed the provider to 
what type of bill would be appropriate for the corrected claim. The citation the plan used does not contain any 
information about type of bill. Therefore, we decided that the Plan has to pay for home health services  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on February 17, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you say that your doctor is lying to get 
more money. 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 $45 
copayment for outpatient substance abuse services.  
 
You have been asked to pay $45 copayment for office visit. This item/service falls within the outpatient 
substance abuse 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 office visit 
provided on February 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF care was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that the Maximus reviewer did
not consider that at the time of the appeal, the enrollee's ability to participate in therapy was described as
limited due to anxiety, fear, memory problems, and weakness. The records show the enrollee did not require
physician supervision by a rehabilitation physician at least 3 days per week.
The Plan is correct in this case. 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.
Based on this information and review of the medical records, we decided that Medicare rules for coverage of
IRF care were not met at the time of the appeal. Therefore, we decided that the Plan does not have to provide
coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 24, 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 May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery (D4261) provided on September 3, 2021. 
 
You asked the Plan to pay for the osseous surgery (D4260). You say that the service is a covered benefit. 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 
osseous surgery (D4261) provided on September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel test provided on January 3, 
2022. 
 
You asked the Plan to pay for the respiratory pathogen panel test. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that that panels with greater than five respiratory 
pathogens performed in the Part B outpatient setting are considered not medically reasonable and necessary. 
 
We looked at the file and Medicare rules. The service rendered is specifically not covered. Based on this 
information, we decided that Medicare rules for coverage of the respiratory pathogen panel test have not been 
met. Therefore, we decided that the Plan does not have to pay for the respiratory pathogen panel test provided 
on January 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on March 8, 
2020. 
 
You asked the Plan to pay for the subsequent hospital care. You say that the claim was initially submitted 
within the time filing frame, but was submitted to the incorrect payer. You also say that you would like this 
claim to be reprocessed. The Plan denied your request. The Plan says this claim was untimely and was not filed 
until June 9, 2022, more than a year after the date of service of March 8, 2020. 
 
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 subsequent hospital care was not filed until June 9, 2022. 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 subsequent hospital care (99232) provided on March 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a modification of removable prosthesis following 
implant surgery (D5875 x 2), surgical placement of implant body endosteal implant (D6010 x 2), surgical 
access to an implant body (D6011 x 2), custom fabricated abutment includes placement (D6057 x 2), 
therapeutic parenteral drug single administration (D9610), deep sedation/general anesthesia first 15-minutes 
(D9222) and deep sedation/general anesthesia each subsequent 15-minute increment (D9223 x 2).  You asked the Plan to pre-approve the dental services. You say that these services should be covered since 
traditional dentures will not work for you. The Plan denied your request. The Plan says these services are either 
not covered under your dental plan or no documentation was received to support medical necessity. 
 
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. Additionally, the record shows your provider did not submit 
documentation to support the medical necessity of the request for sedation services. Therefore, we decided that 
the Plan does not have to pre-approve a modification of removable prosthesis following implant surgery 
(D5875 x 2), surgical placement of implant body endosteal implant (D6010 x 2), surgical access to an implant 
body (D6011 x 2), custom fabricated abutment includes placement (D6057 x 2), therapeutic parenteral drug 
single administration (D9610), deep sedation/general anesthesia first 15-minutes (D9222) and deep 
sedation/general anesthesia each subsequent 15-minute increment (D9223 x 2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on July 18, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving the enrollee a 
"referral." 
 
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 lab testing provided on July 18, 2022, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45915 billed for date of service April 19, 
2022. 
 
You asked the Plan to pay for procedure code 45915. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 45915 is bundled into payment for code 45330. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 45915 
is a column II code to column I code 45330. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 45915 billed for date of service April 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on May 04, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $255 copayment for each one-way Medicare-covered ground ambulance tip. Covered ambulance 
services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that 
can provide care if they are furnished to a member whose medical condition is such that other means of 
transportation could endanger the persons health or if authorized by the plan. The provider billed in the 
amount of $385 and the allowed amount is $171.37. This is less than the copayment amount. Therefore, results 
in the total cost sharing amount of $171.37. 
 
 
 
 The enrollee has been asked to pay a $171.37 copayment, which is less than the copayment for ambulance. 
This item/service falls within the Ambulance 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 ambulance on May 04, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a fourth Positron Emission Tomography (PET)
scan for the enrollee.
You asked the Plan to provide coverage for a fourth PET scan. You say that this imaging is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that while there is no disagreement
regarding the enrollee's condition, continued PET scans are not typically covered.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say Medicare does not
covered more than three PET scans for treatment strategy. The medical records show the enrollee has had three
previous PET scan. Therefore, we decided that the Plan does not have to provide coverage for a fourth Positron
Emission Tomography (PET) scan for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF care was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria. The Plan states the medical records did not show that at the time of the appeal you required
physician supervision by a rehabilitation physician at least 3 days per week or an interdisciplinary team to
manage your condition.
The Plan is correct in this case. 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.
Based on this information, and the medical records, the Medicare rules for coverage of IRF care were not met
at the time of the appeal. Therefore, we decided that the Plan does not have to provide coverage for acute
inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for add tooth to existing partial denture (D5650) provided on 
October 15, 2021. 
 
You asked the Plan to pay for add tooth to existing partial denture. You say that you feel this service should be 
covered like crowns are covered. The Plan denied your request. The Plan says this service is not covered under 
your benefits. 
 
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 add tooth 
to existing partial denture (D5650) provided on October 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
7, 2022, to April 13, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the NOA and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the provider 
did not bill with an appropriate Q code on the claim. Therefore, we decided that the Plan does not have to pay 
for the home health services provided to the enrollee from April 7, 2022, to April 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) on 
June 09, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you want to appeal the amount being 
charged. 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 per day for other Medicare-covered diagnostic radiology services that are not ultrasounds. You will 
only pay one copayment per day even if multiple diagnostic radiology services are performed. Covered 
services include, but are not limited to diagnostic radiology services, such as ultrasound, nuclear cardiac 
imaging, PET, MRI, and CT scan. 
 
 You have been asked to pay a $250 copayment for MRI. This item/service falls within the Outpatient 
diagnostic tests and therapeutic services and supplies 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 magnetic resonance imaging (MRI) on June 09, 2022.