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. The Plan denied your request. The Plan says the enrollee's needs 
can safely be met 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 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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for anemia. The complexity of the enrollees nursing, 
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5259) purchased on July 1, 2021. 
 
You asked the Plan to pay for hearing aids. You say that you would like to be reimbursed the full amount you 
are entitled to with your policy. You know you were out-of-network and may have a bigger copayment 
required. The Plan denied your request. The Plan says you do not have out-of-network benefits for hearing 
aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased from the specified hearing vendor.  
 
We looked at the file and the Plan's rules. The hearing aids in this case were purchased from a provider who 
does not participate in the specified routine hearing vendor network. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not 
have to pay for the hearing aids (V5259) purchased on July 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
July 5, 2021, to July 8, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided. 
 
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 $200 copayment per day for days 1-5 of Inpatient hospital care.  
 
The enrollee has been asked to pay a $600 copayment for 3 days of inpatient hospital care ($200 x 3 = $600). 
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 inpatient hospital services provided from July 
5, 2021, to July 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the hospital care while in an inpatient stay 
provided on December 4, 2021. 
 
You asked the Plan to waive the deductible for the hospital care while in an inpatient stay. You say that you 
met your deductible and the service rendered should fall under Medicare Part B. The Plan denied your request. 
The Plan says the service provided falls under Medicare Part A, so the proper deductible was correctly 
assessed. 
 
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 a $1,484 deductible which applies per plan year for most Part A in-
network and out-of-network services. Prior to the date of service, the total amount paid towards the $1,484 
deductible was $414.18 leaving $1,069.82 ($1,484 yearly deductible - $414.18 paid towards deductible) to be 
paid towards the yearly deductible. The total amount allowed for the service provided was $78.07. Therefore, 
$78.07 was charged as the deductible since that is less than the $1,069.82 left of the deductible to be paid. 
 The item or service you asked the Plan to waive the deductible for falls within the benefit category per plan 
year for most Part A in-network and out-of-network services. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,484 deductible which applies per plan year for most Part A in-
network and out-of-network services. This cost sharing is a contractual obligation that had not been met at the 
time the hospital care while in an inpatient stay was received on December 4, 2021. Therefore, we decided that 
the Plan does not have to waive the deductible for the hospital care while in an inpatient stay provided on 
December 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound debridement of the subcutaneous tissue provided on 
August 2, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for wound debridement of the subcutaneous tissue. You say that you thought that 
you were in network with the Plan, and you are not. The Plan denied your request. The Plan says the rendering 
provider is a non-participating provider and there is no referring provider involved in these services. The Plan 
also says that they did not authorize any services for the rendering provider nor for the facility. 
 
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 wound debridement of the subcutaneous tissue 
provided on August 2, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Office Visit on December 7, 2021. 
 
You asked the Plan to waive the copayment for an Office Visit. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $25 
copayment for an Office Visit.  
 
You have been asked to pay a $25 copayment for an Office Visit. An Office Visit falls within the Podiatry 
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 an Office Visit on 
December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removable prosthodontic procedure (D5899) provided on 
January 14, 2022. 
 
You asked the Plan to pay for the removable prosthodontic procedure. You say that you cannot afford to pay 
this bill. The Plan denied your request. The Plan says this service is not covered under the plan. 
 
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 
removable prosthodontic procedure (D5899) provided on January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bone graft services provided on May 19, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says you were informed these services would not be covered. Maximus
overturned the Plans denial. The Plan requested a reopen and states that the financial agreement you signed was
forwarded for review. In addition, in a recorded call to the Plan you were informed on April 15, 2021, that this
service would not be covered but would be discounted 20 %. That same information was expressed to you at
the appointment on May 19, 2021. In both instances you expressed understanding that you would be
responsible for the cost of these services.
The Plan is correct in this case. Medicare generally does not cover dental services. The Plan offers a dental
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit more than Medicare coverage, bone graft replacement is not among
those covered under this benefit. The Plan has demonstrated that you signed a financial agreement and were
made fully aware of this cost prior and on the date of service. Therefore, we decided that the Plan does not have
to pay for bone graft services provided on May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited dental exam rendered on November 8, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services exhausted the benefit limit. 
 
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. The Plan covers one limited 
exam per plan year.  
 
We looked at the file and the Plans rules. The file shows that you previously had a limited exam on March 26, 
2021 that the Plan covered. The limited exam on November 8, 2021 was the second limited exam performed in the same plan year. Based on this information, we decided that the Plan's rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the limited dental exam 
rendered on November 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from May 16, 2019, to
May 30, 2019.
You asked the Plan to pay for this claim. You say that this claim should be paid by the Plan. The Plan denied
your request. The Plan says the records provided do not support the services billed. Maximus overturned the
Plans denial. The Plan requested a reopen and provided additional information.
Our Medical Director looked at the case file and the reopen request. At issue is the DRG payment for inpatient
services rendered. Maximus determined that payment was appropriate as originally billed. The Plan requested a
reopen and submitted new and material evidence. The medical records show the enrollee was an 80-year-old
woman with a history of COPD, diabetes, chronic kidney disease, and a recently diagnosed lung tumor, who
was admitted to the hospital on May 16, 2019, with acute-on-chronic hypoxic respiratory failure due to postobstructive
pneumonia, a right lung mass with pleural effusion with lymphadenopathy and adrenal masses
worrisome for malignancy, and COPD exacerbation. The enrollee expired on May 30, 2019.
The principal diagnosis of C34.2 Malignant neoplasm of middle lobe, bronchus or lung was reported by the
hospital. Documentation supported an admission for J90 Pleural effusion, pneumonia, COPD exacerbation, and
respiratory failure. Treatment was for and directed to the pleural effusion and the other respiratory conditions.
There was no treatment for cancer. Per coding guidelines, the principal diagnosis would be the condition which
led to the hospital inpatient admission which was J90.
Our Medical Director has determined that the Plan is correct in this case. The Plan notes that a principal
diagnosis of malignant neoplasm of the middle lobe, bronchus, or lung was not appropriate. The documentation
supports that principal diagnosis would properly reflect acute-on-chronic respiratory failure with hypoxia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient care provided to the enrollee from May 16, 2019, to May 30, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital with 
sepsis and a urinary tract infection (UTI). You received oral medications and had stable vital signs. You 
received physical and occupational therapy in the hospital and need maximum assistance with functional 
mobility. You need varied assistance with activities of daily living. You are non-weight bearing to your left leg. 
You have no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily 
basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
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 need rehab for continued recovery. The Plan 
denied your request. The Plan says care can be provided safely in a less intensive setting. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for peripheral vascular disease, below the knee amputation, 
congestive heart failure, and encephalopathy. Your medical problems are stable. The complexity of your 
nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided January 25, 2022. 
 
You asked the Plan to pay for the limited oral evaluation. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this service is non-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. 
 
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 a limited oral evaluation (D0140) provided 
January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre Continuous Glucose Monitor 
(CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you would like reconsideration because the CGM is 
medically necessary. The Plan denied your request. The Plan says the medical records submitted do not 
establish that the Freestyle Libre 14 Day Sensor is reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the FreeStyle 
Libre Continuous Glucose Monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Angiography provided on July 26, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Angiography. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says prior authorization is required for an out-of-network office visit. 
 
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 Angiography provided on July 26, 2021 by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Angiography provided on October 25, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Angiography. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says prior authorization is required for an out-of-network office visit. 
 
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 Angiography provided on October 25, 2021 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on June 29, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that the rendering provider does not have direct access 
or interaction with patients prior to performing the testing. You also say that the treating physician determined 
that ordering the test is medically necessary for the patient to assist in treatment decisions. The Plan denied 
your request. The Plan says no prior authorization is on file for these services, and based on their records, it 
shows the provider was informed that prior authorization is required for this service. The Plan also says that the 
referring provider was non-participating on the date of service. 
 
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 genetic testing provided on June 29, 2021, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test provided on November 2, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the drug test. You say that you have a capitation agreement with the Plan. The 
Plan denied your request. The Plan says you are an out-of-network provider. 
 
  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 the drug test provided on November 2, 2021, by 
an OON provider.