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

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge on tooth #23 (D7953). 
 
You asked the Plan to pre-approve bone replacement graft for ridge on tooth #23. You say that the service is 
necessary. The Plan denied your request. The Plan says the requested 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 pre-approve bone 
replacement graft for ridge on tooth #23 (D7953).
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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says LTACH admission is not medically necessary because 
the enrollee's needs are being met at the current facility. 
 
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 the enrollee was admitted with acute hypoxic respiratory failure with vent-
dependency, recent tracheostomy. Per the reviewed documentation the enrollee is not medically stable for care 
transition; has not completed acute hospital course at this time; new febrile course with elevated white blood 
cell (WBC) count up to 22.63 on October 25, 2022 from 8.13 on October 24, 2022; concerning for sepsis or 
underlying infection; started on IV Abx (Cefepime); blood cultures pending. Updated clinical information from 
October 27, 2022, says that the enrollee remains unstable, has a recent fever =, elevated WBC started on IV 
antibiotics, blood culture pending. 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. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemzar and Mvasi for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the use of these drugs for Stage IVB metastatic endometrial carcinoma is not Food and 
Drug Administration (FDA) approved, or listed in the Medicare-approved compendia. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drugs are not medically reasonable or necessary. Our physician reviewer found that either of these 
drugs would be approved as a single agent. However, the combination of these drugs is not evidence-based. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gemzar and Mvasi for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis represented by code 
D7473. 
 
You asked the Plan to pre-approve the removal of torus mandibularis. You say that you need the removal of 
torus mandibularis before getting dentures. The Plan denied your request. The Plan says the service is not 
covered under your benefit package. 
 
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 the 
removal of torus mandibularis represented by code D7473.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is necessary because you live alone and 
have no one to assist you. You said that you are struggling with your daily living needs and are unable to care 
for yourself. The Plan denied your request. The Plan says SNF care is not medically necessary for you. 
 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you recently had a right knee replacement. You have been treated for your pain and 
you have stable vital signs. You currently have no identifiable skilled nursing needs.  While you do have 
skilled therapy needs, it is not necessary for you to receive therapy on a daily basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
 
 
 
 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 HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has COPD. There is no diagnosis 
of cystic fibrosis, bronchiectasis, or neuromuscular disease. The enrollee does not have a diagnosis for which 
Medicare covers this device. The device has not been demonstrated to be beneficial in the treatment of COPD. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need 24/7 help to assist you getting around and 
into the hospital bed. The Plan denied your request. The Plan says 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are a 71-year-old female with chronic obstructive pulmonary disease (COPD), 
lung cancer and pneumonia. From a nursing perspective, you received oral and inhaled medications. You have 
stable vital signs, and you were treated for toe pain. You were at a stand-by assist level with functional mobility 
including gait to 200 feet.  You require varying assistance with activities of daily living. You have no 
identifiable skilled nursing service needs. While you do have identifiable skilled therapy service needs, you do 
not require therapy on a daily basis.  You also do not require these services in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ultrasound of the extracranial arteries
provided on November 18, 2021.
You asked the Plan to waive the coinsurance for these services. You say that you thought this was covered at
100%. The Plan denied your request. The Plan says that you have been charged the correct cost sharing
amount.
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The
Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible.
The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays
covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last
resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing
home care, personal care, and home and community-based services). These services qualified under the
Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are
covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid
coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits.
Therefore, we decided that the Plan does not have to waive the coinsurance for the ultrasound of the
extracranial arteries provided on November 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the breast ultrasound, tomosynthesis, and
diagnostic mammogram performed on July 8, 2021.
You asked the Plan to waive the coinsurance for the ultrasound, tomosynthesis, and mammogram. You say that
the services should have been covered. The Plan denied your request. The Plan says that the correct
coinsurance was applied.
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The
Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible.
The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays
covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last
resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing
home care, personal care, and home and community-based services). These services qualified under the
Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are
covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid
coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits.
Therefore, we decided that the Plan does not have to waive the coinsurance for the breast ultrasound,
tomosynthesis, and diagnostic mammogram performed on July 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the cataract surgery provided on
November 22, 2021, to December 6, 2021.
You asked the Plan to waive the coinsurance for the cataract surgery. You say that you cannot afford to pay
these charges. The Plan denied your request. The Plan says that these services must be addressed under your
Medicaid benefit by your provider.
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The
Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible.
The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays
covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last
resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing
home care, personal care, and home- and community-based services). These services qualified under the
Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are
covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid
coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits.
Therefore, we decided that the Plan does not have to waive the coinsurance for the cataract surgery provided on
November 22, 2021, to December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit in an outpatient hospital
setting provided on January 19, 2022.
You asked the Plan to waive the copayment for the office visit. You say that your surgery was approved and
covered. 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 $295
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital. You have
been asked to pay a $120.76 copayment for the office visit. The visit was in an outpatient hospital setting and
not a physician's office. This item/service falls within the Medicare-covered surgery or other services provided
to you at an outpatient hospital benefit category. The allowed amount for the visit was less than the assigned
copayment for these services and therefore you were charged the allowed amount of $120.76. This means that
you have been asked to pay less than 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 the office visit in an outpatient hospital setting provided on January
19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs provided on September
23, 2021, and October 21, 2021.
You asked the Plan to waive the coinsurance for the Part B drugs. You say that the drug charges should be
included into the copayment for outpatient surgery. 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 20%
coinsurance for Medicare-covered Part B drug. You have been asked to pay a 20% coinsurance for the Part B
drugs. This item/service falls within the Medicare-covered Part B drug benefit category. The Part B drugs are
not packaged with the outpatient surgery you received. 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
the Part B drugs provided on September 23, 2021, and October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for the office visit or pay for the refraction provided on
December 17, 2021
You asked the Plan to fully pay for the office visit or pay for the refraction. You say that you agreed to pay
because it was your understanding that the doctors fee was covered by the Plan. 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. Your
contract with the Plan says that enrollees must pay a $25 copayment for Medicare-covered vision services at a
specialist's office. Plan rules also state that a refraction is only covered with a routine eye exam.
The Plan says you must pay a $25 copayment for the office visit. This item/service falls within the Medicare covered
vision services at a specialist's office 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. The records show a routine eye exam was not performed for the refraction
to be covered. Therefore, we decided that the Plan does not have to fully pay for the office visit or pay for the
refraction provided on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) acupuncture treatments.
You asked the Plan to pre-approve ten (10) acupuncture treatments. You say that you are requesting a
reconsideration of the Plan's denial. The Plan denied your request. The Plan says that the requested services
have been denied as you do not have a qualifying diagnosis.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case. The Plan will only cover acupuncture for one of the following indications:
1. Postoperative or chemotherapy induced nausea and vomiting;
2. Nausea and vomiting of pregnancy;
3. Chronic low back, neck, or shoulder pain;
4. Chronic migraines or moderate to severe chronic tension headaches, defined as headaches greater
than14 days per month for more than 3 months;
5. Pain from clinically diagnosed osteoarthritis of the knee
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, you do not have a Medicare covered diagnosis of
chronic low back pain. The file also indicates acupuncture is being requested for Dupuytren's contracture,
which is not a Plan covered indication. Therefore, we decided that the Plan does not have to pre-approve ten
(10) acupuncture treatments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and extraction (D7210)
provided from December 1, 2021, to December 13, 2021.
You asked the Plan to pay for the limited oral evaluation and extraction provided from December 1, 2021,
through December 31, 2021. You say that you were not told that the doctor had opted out of Medicare. The
Plan denied your request. The Plan says that this provider has opted out of Medicare and is not eligible for
payment.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a
non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. The facility
these services were performed in also confirmed they do not accept Medicare. Therefore, we decided that the
Plan does not have to pay for the limited oral evaluation (D0140) and extraction (D7210) provided from
December 1, 2021, to December 13, 2021.