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 the enrollee has unstable vital laboratory work and 
needs monitoring. The enrollee is able to tolerate three hours of physical therapy. The Plan denied your request. 
The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower level of 
care such as a 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 the enrollee's diagnosis of dyspnea without documented respiratory failure is not an 
IRF compliant diagnosis. The record does not show that the enrollee will continue to require close medical 
supervision on an inpatient basis. Although the documentation shows that the enrollee could tolerate three 
hours of therapy the IRF criteria has not been met and is not medically 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 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 procedure code 70450 billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 13, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that due to the enrollee's age, the enrollee meets the need 
for medical oversight and needs to be in an IRF. The Plan denied your request. The Plan says that the IRF care 
is not medically necessary, and the enrollee's needs can be met at a lower level of care such as a 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the records shows the enrollee has multiple active comorbidities including syncope and lymphoma and 
will continue to require close medical supervision on an inpatient basis. The enrollee's evaluating therapists 
(physical therapy, occupational therapy) state that the enrollee requires intense therapy and will tolerate three 
hours of therapy per day. The enrollee also requires speech therapy for dysphagia per evaluating speech 
therapist which means IRF criteria has 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the $150 copayments charged for cataract surgery services provided December 13, 2021, and January 5, 2022.
You asked the Plan to waive this cost share. You say that you do not believe these copayments are correct. The Plan denied your request. The Plan says each copayment was charged for the surgery provided and the Plan contract agreement. Maximus partially overturned the Plans denial because one of the Plan contracts was not submitted for review. The Plan requested a reopen and provided the required contract information.
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 $150 copayment for each outpatient surgery.
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 $150 copayments charged for cataract surgery services provided December 13, 2021, and January 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Vabysmo injection provided on April 
28, 2022. 
 
You asked the Plan to waive the coinsurance for a Vabysmo injection. You say that you cannot afford these 
coinsurance amounts. The Plan denied your request. The Plan says you were charged this cost sharing 
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 20% 
coinsurance for Medicare Part B chemotherapy drugs and other Part B drugs. The allowed amount of this drug 
is $1427.18 resulting in a $285.44 coinsurance ($1427.18 x 20% = $285.44). 
 
You have been asked to pay a $285.44 coinsurance for a Vabysmo injection. A Vabysmo injection falls within 
the Medicare Part B Prescription Drugs 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 a Vabysmo injection provided on April 28, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for a specialist office visit 
provided on March 24, 2022. 
 
You asked the Plan to waive the deductible and coinsurance for the specialist visit. You say that you did not 
have any copayments before you changed doctors. The Plan denied your request. The Plan says the correct 
deductible and coinsurance were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $233 deductible which applies to certain items and services.  
 
The specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $233 deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the specialist visit was received on March 24, 2022.  
 
The file shows that on the date of service, you had a total of $109.62 remaining to meet your deductible. Once 
this was met, the 20% coinsurance was applied to the remainder, coming to $1.78 ($118.50 allowed amount - 
$109.62 deductible = $8.88 x 20% coinsurance = $1.78). The total for the deductible and coinsurance amounts 
is $111.40. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance for a 
specialist office visit provided on March 24, 2022.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for out of network palliative care for the enrollee.
You asked the Plan to provide coverage for out of network palliative care for the enrollee. The Plan denied your request. The Plan says there were several providers in network who could provide this care. Maximus overturned the Plans denial stating this care was necessary. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan also noted the enrollee passed before she would have been transferred.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must provide coverage for 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 services requested. The enrollee was clearly at the state of end of life with no medical reason to transfer out of network and ultimately passed prior to any transfer. Therefore, we decided that the Plan does not have to provide coverage for out of network palliative care for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 that 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the documentation shows that the enrollee has multiple active comorbidities and hospital complications 
and would be expected to continue to require close medical supervision. Evaluating therapists recommend 
intense therapy in an IRF thus IRF criteria has been met and is medically 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code L5671 for services provided to the enrollee
on October 11,2021.
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 they previously paid two units for procedure code L5671 on December 08, 2021, under
a previous claim number. Therefore, the billing of procedure code L5671 exceeds the unit value allowed for
this code. Maximus overturned the Plans denial for insufficient documentation of the previous payment. The
Plan requested a reopen and provided the required claim information.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes and when required the appropriate number of units.
In this case, the second claim exceeds the number of units allowed to be billed for code L5671.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for procedure code L5671 for services provided to the enrollee on October 11, 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 enrollee currently meets IRF admission. You say 
that the enrollee is a high risk for falls and a high risk for injury. The Plan denied your request. The Plan says 
the IRF care is not medically necessary, and the enrollee's needs can be met at a lower level of care such as a 
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 the enrollee's diagnoses include acute respiratory failure due to infection with the 
COVID-19 virus, with tracheostomy and a feeding tube. The enrollee has stabilized medically and no longer 
requires mechanical ventilation. In this case, the complexity of the enrollee's nursing, medical and 
rehabilitation needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary 
approach to rehabilitation 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the requested services.
You asked the Plan to provide coverage for these services. You that at the time of the appeal this treatment was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for three levels of
treatment were not met. Maximus overturned the Plans denial stating this treatment was necessary. The Plan
requested a reopen and stated that the Maximus reviewer did not address the number of levels requested.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules state that the need for a three or
four-level procedure bilaterally may be considered under unique circumstances and with sufficient
documentation of medical necessity on appeal. Based on the records provided, the original review did not
address the number of levels requested and the records are insufficient to show special circumstances were
present to allow a three-level procedure. Therefore, we decided that the Plan does not have to provide coverage
for three level lumbar spine medial branch blocks (MBB).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 16, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 
 The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cystourethroscopy (procedure code 52334) provided to the 
enrollee on April 6, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 52334 is "Cystourethroscopy with insertion of ureteral 
guide wire through kidney to establish a percutaneous nephrostomy, retrograde." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that thre records do not support that 
CPT 52334 - cystourethroscopy with insertion of ureteral guide wire through kidney to establish a percutaneous 
nephrostomy, retrograde - was actually rendered in this case. Cystoscopy, ureteroscopy and stent placement 
was rendered on 4/6/22 and not retrograde percutaneous access procedure.   
We looked at this coder'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 pay for cystourethroscopy (procedure code 52334) provided to the enrollee on April 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 12, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92012) and eye refraction (92015) provided 
on January 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam and eye refraction. You say that you have been seeing this provider 
and going to this facility for a while. You also say that you were unaware the treating provider was OON. The 
Plan denied your request. The Plan says these services were rendered by a provider who is not in the Plan's 
vision care 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 the eye exam (92012) and eye refraction (92015) 
provided on January 12, 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 dental crown (D2750) 
 
You asked the Plan to pre-approve the dental crown. 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 the x-
rays provided are not indicative of the need for a crown as it would not be beneficial. 
 
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 
dental crown (D2750)