Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional physical therapy (PT) visits in your home. 
You asked the Plan to pre-approve 5 additional PT visits. You say that the enrollee does not feel well enough to 
do a lot of walking on their own. You also say that the PT is needed to prevent atrophy and losing strength. The 
Plan denied your request. The Plan says the additional PT visits are not medically necessary. 
 
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 5 additional PT visits. Our reviewer 
says that the additional home health PT services are not medically necessary. Our physician reviewer found the 
provided documentation does not indicate that the enrollee has documented, ongoing, home health PT needs. 
Therefore, the reviewer found that ongoing, home health PT services are not medically necessary or 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 5 additional physical therapy (PT) visits in your home.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric care from April 15, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the services at issue are 
medically necessary. The Plan denied your request. The Plan says that the services at issue are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that the services are medically necessary and reasonable. Our physician reviewer found 
based upon review of the records provided it was expected this enrollee would improve in a reasonable period 
of time as he did have dangerousness to self but not others. He had no auditory or visual hallucinations, 
delusions and was not showing any behavioral issues. It did appear that active treatment was taking place. It 
did appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of 
care rather than 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 inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve inpatient psychiatric care from April 15, 2022, forward.  
   
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated post and core (D2954) provided on 
November 9, 2021. 
 
You asked the Plan to pay for the prefabricated post and core. You say that this service was necessary. You 
also say that you had to rebuild a tooth and crown because it was cracked. The Plan denied your request. The 
Plan says prefabricated post and core is not listed as a covered service. 
 
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 prefabricated post and core is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
prefabricated post and core (D2954) provided on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endodontist consultation provided on January 5, 2022. 
 
You asked the Plan to pay for endodontist consultation. You say that you were told the cost of this examination 
would be $52 and were surprised when you got a bill for $67. The Plan denied your request. The Plan says this 
service is not covered by the Plan's dental 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 an 
endodontist consultation provided on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two of the periapical dental x-rays (code D0230) you 
received on December 15, 2021. 
 
You asked the Plan to pay for the two periapical x-rays. You say that you went to your dentist for a regular 
cleaning.  You claims that the dentist did unnecessary x-rays so you should not have to pay for them. The Plan 
denied your request. The Plan says you had three x-rays on this date of service.  You are only covered for one 
intraoral x-ray per year, so the second and third x-rays you received are not covered. 
 
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 contract explicitly 
states that you are only covered for one periapical x-ray per calendar year. 
 
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 two of the 
periapical dental x-rays (code D0230) you received on December 15, 2021.  
Your complaint about the x-rays being unnecessary is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic procedure (D0999) provided on February 8, 2021. 
 
You asked the Plan to pay for the diagnostic procedure. You say that comprehensive dental services are 
included in the wallet provision. The Plan denied your request. The Plan says this service is not covered by 
your plan. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
diagnostic procedure (D0999) provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to waive the copayment for physician services provided on August 25,
2021.
You asked the Plan to waive this copayment. You say that you do not believe this cost share is correct. The
Plan denied your request. The Plan says this cost share was applied based on the claim submitted by the
provider and the Plan contract agreement. Maximus overturned the Plans denial. The Plan requested a reopen
and stated Maximus did not apply the correct contract criteria.
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 $15 copayment for specialist services. The records do not show this was billed
by your provider as a post operative follow up. 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
physician services provided on August 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) guidance for placement of
radiation therapy fields (77014) provided on March 17, 2021.
You asked the Plan to pay this claim. You say that this imaging should be covered by the Plan. The Plan denied
your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial
for insufficient information in the case file to explain the denial. The Plan requested a reopen and stated that
based on the Medicare billing guidelines, code 77014 is included in the APC payment for code 77301 (IMRT
planning).
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. Medicare does not allow
the billing of code 77014 in addition to the billing of code 77301. Medicare billing criteria were not met.
Therefore, we decided that the Plan does not have to pay for computed tomography (CT) guidance for
placement of radiation therapy fields (77014) provided on March 17, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the health plan approved the coverage of 
SAR services through 4/11/2022. The health plan has not argued that the transfer from the swing bed to the 
nursing facility was medically unnecessary. Therefore, the health plan should cover the previously approved 
SAR services, regardless of the enrollees location, through 4/11/2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
 
 
 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography services provided to the enrollee on
July 19, 2020, and paid under code 70450.
You asked the Plan to pay this claim. You say that this imaging should be paid by the Plan. The Plan denied
your request. The Plan says this code is included in a service that was previously paid by the Plan. Maximus
overturned the Plans denial for insufficient proof of payment. The Plan requested a reopen and provided the
required payment information. The Plan says that mutually exclusive edits consist of combinations of
procedures that differ in technique or approach but lead to the same outcome. In some instances, the
combination of procedures may be anatomically impossible. Procedures that represent overlapping services are
considered mutually exclusive. Procedures 70450 and 70496 include imaging of the head or brain. Procedure
70496 however, is a more comprehensive procedure that includes imaging procedures 70450 as well as
additional components. The Plan submitted proof of payment for code 70496 which was done on July 23, 2021,
and provided a copy of that proof of payment.
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 this claim for
70450 cannot be paid as billed as payment for this service was included in a previous payment.
Therefore, we decided that the Plan does not have to pay for computed tomography services provided to the
enrollee on July 19, 2020, and paid under code 70450.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure. 
 
You asked the Plan to pre-approve Intracept procedure. 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 Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will do well in an LTACH 
level of care, and his complex medical issues can be safely managed there as he slowly continues to make 
improvements. The Plan denied your request. The Plan says authorization denied because LTACH 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) 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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says IRF care is not medically necessary for the patient. They have not 
completed their full acute hospital treatment because of high blood pressure requiring intensive monitoring. 
The patient's medical condition requires further care in the acute care hospital. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for stroke and hypertension. Their medical problems are stable and there are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the SNF care is medically necessary. The Plan 
denied your request. The Plan says that authorization denied because the SNF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
SNF care is medically necessary. Our physician reviewer found based on the documentation provided, the 
enrollee qualifies for SNF coverage. The enrollee does not have documented skilled nursing needs.  The 
enrollee does have documented skilled therapy needs. Strength and endurance training is medically necessary 
and reasonable. Daily skilled services are required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 pre-approve a non-preferred brand of diabetic supplies. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the 
enrollee does not meet the coverage criteria. 
 
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 brand of diabetic supplies is not a preferred brand. The Plan has preferred brands available for 
the enrollees condition. There is no indication the enrollee is unable to use items that are not a preferred brand. 
We found no exception that would require the Plan to pre-approve these preferred items. Therefore, we decided 
that the Plan does not have to pre-approve a non-preferred brand of diabetic supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vertiflex device placement surgery (22869, 22870). 
 
You asked the Plan to pre-approve the vertiflex device placement surgery. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is experimental. 
 
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 vertiflex device placement surgery. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this service is experimental and more research is needed to show safety and 
efficacy. 
 
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 vertiflex device placement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the vertiflex device placement surgery (22869, 22870).