Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that the coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the documentation does not support medical necessity for admission to an IRF. 
You have no medical complexity, and no rehabilitation nursing needs other than routine nursing care and are 
highly functional with low endurance. While you may benefit from physical therapy and occupational therapy, your rehabilitation needs can be safely met in an alternate and low intensity setting such as in a skilled nursing 
facility. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to waive the cost share dental services provided from October 12, 2021, to January 20, 2022.
You asked the Plan to waive these services. 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 correctly. Maximus overturned the Plans denial for insufficient contract information in the case file. The Plan requested a reopen and provided the required information. The Plan sates the decision to apply the in question was cored. The 2021 and 2022 Plan contract states there is a 20% coinsurance for the following comprehensive dental services: restorative services, endodontics, periodontics and extractions. In addition, code D1206 is a non-covered service.
Medicare 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.
Based on the records provided, this cost share was applied correctly based on what was covered under the Plan contract. In addition, code D1206 is not a covered service. Therefore, we decided that the Plan does not have to waive the cost share dental services provided from October 12, 2021, to January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for to pay for genetic testing provided to the enrollee on April 21, 2021.
You asked the Plan to pay for these services. You say that this testing should be covered by the Plan. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Tempus xF Panel testing, a liquid biopsy of 105 genes, provided on April 21, 2021. The Maximus Physician Reviewer determined this service was determined to be reasonable and medically necessary. The Plan requested a reopen and argued there was no evidence that the enrollee was unable to undergo traditional biopsy testing. The Plan is correct in this case. The medical records show the enrollee has metastatic prostate cancer. The documentation does not support that the coverage criteria for the Tempus genetic testing in this case met the NDC criteria for Next Generation Sequencing. This genetic testing does not have FDA approval or clearance as a companion in vitro diagnostic, and an FDA approved or cleared indication for use in this enrollee's cancer. In addition, there is insufficient evidence in the medical literature to support the utility of Tempus xF Panel testing for prostate cancer. 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 pay for to pay for genetic testing provided to the enrollee on April 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for duplex scan of extracranial arteries 
provided on July 22, 2022. 
 
You asked the Plan to waive the copayment for duplex scan of extracranial arteries. You say that you think 
your $90 copay should be reduced to a $60 copay. 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 $90 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $90 copayment for duplex scan of extracranial arteries. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for duplex scan of extracranial arteries provided on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213), and mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the maxillary partial denture (D5213), and mandibular partial denture 
(D5214). The Plan denied your request. The Plan says these services are not covered under the 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 a 
maxillary partial denture (D5213), and mandibular partial denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says the Intracept is unproven and not medically 
necessary as the published studies are of generally poor or fair quality. 
 
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 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 before coverage can 
be approved. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dermatologist office visit provided on July 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a dermatologist office visit. You say that you were under the assumption that the 
member's insurance card stated that no referral was needed, and visit would be covered by the Plan. The Plan 
denied your request. The Plan says an authorization was not obtained prior to services rendered. 
 
  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 a dermatologist office visit provided on July 28, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you can only go a short distance using 2 
canes. The Plan denied your request. The Plan says you do not need the scooter in your home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
We looked at the file and the rules. The records show that you live in an upstairs apartment without elevator 
access. The records do not show that your home provides adequate access for the requested scooter. The 
requested scooter is for use outside of the home. Although this item may be helpful, neither Medicare nor the 
Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-
approve a power scooter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered ambulance mileage (A0888) provided on 
June 10, 2022. 
 
You asked the Plan to pay for the ambulance mileage. You say that you were not able to get into a car to go to 
the hospital. You say that you called an ambulance. You say that you are happy to pay the copayment. You also 
say that you should not have to pay the remaining amount. The Plan denied your request. The Plan says 
mileage to the out-of-area hospital is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only mileage to the nearest appropriate facility 
equipped to treat the patient is covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance mileage have not been met. Specifically, the record shows that you requested to be 
taken to a hospital other than the hospitals the ambulance does drop off too. Therefore, we decided that the Plan 
does not have to pay for the non-covered ambulance mileage (A0888) provided on June 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve leqvio. 
 
You asked the Plan to pre-approve leqvio. You say that the drug is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 leqvio. Our reviewer says that the 
elements of the coverage criteria are not satisfied. Our physician reviewer found the Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition and the Medicare 
approved drug compendia does not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve leqvio.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341 x4). 
 
You asked the Plan to pre-approve the periodontal scaling and root planing - four or more teeth per quadrant 
(D4341 x4). You say that the service is medically necessary. The Plan denied your request. The Plan says your 
x-rays do not show that you have noticeable bone loss or a hard substance built up on the root of the tooth. 
 
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 the 
periodontal scaling and root planing - four or more teeth per quadrant (D4341 x4) when the services are 
medically necessary and reasonable.  
 
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 periodontal scaling and root planing 
- four or more teeth per quadrant (D4341 x4). Our reviewer says that there is no record of periodontal charting 
and the radiographs were inadequate to determine bone loss or subgingival accumulation of calculus.  Our physician reviewer found due to the inadequate documentation, the criteria for coverage for periodontal 
scaling and root planing in four quadrants (D4341) have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the periodontal scaling and root planing - four or more teeth per quadrant 
(D4341 x4) have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal 
scaling and root planing - four or more teeth per quadrant (D4341 x4).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology provided on June 22, 2022, by an OON provider. 
 
You asked the Plan to pay for pathology. You say that you are requesting reimbursement for your services due 
to providing processing and diagnostic reporting to the referring provider. The Plan denied your request. The 
Plan says the enrollee must receive care from a 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 pathology provided on June 22, 2022, by an OON 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown - tooth #1 (D6750), and pontic - 
porcelain tooth #'s 2 and 3 (D6240). 
 
You asked the Plan to pre-approve the retainer crown - tooth #1 (D6750), and pontic - porcelain tooth #'s 2 and 
3 (D6240). You say that you need this dental work done and it is very painful with your gums getting swollen. 
 The Plan denied your request. The Plan says the requested items are not either medically necessary, reasonable 
or both. 
 
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 the retainer 
crown - tooth #1 (D6750), and pontic - porcelain tooth #'s 2 and 3 (D6240) when the services are medically 
necessary and reasonable.  
 
 
 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 retainer crown - tooth #1 (D6750), 
and pontic - porcelain tooth #'s 2 and 3 (D6240). Our reviewer says that the service is not medically necessary. 
Our physician reviewer found a fixed bridge may be covered to replace a single maxillary anterior tooth or two 
adjacent mandibular anterior teeth when no posterior teeth are missing. In this case the teeth to be replaced are 
posterior teeth (#'s 2 and 3) and other posterior teeth are missing. There was no documentation to indicate that a 
removable prosthesis was contraindicated due to a medical issue. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the retainer crown - tooth #1 (D6750), and pontic - porcelain tooth #'s 2 and 3 
(D6240) have not been met. Therefore, we decided that the Plan does not have to pre-approve a retainer crown 
- tooth #1 (D6750), and pontic - porcelain tooth #'s 2 and 3 (D6240).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network specialist office visits 
provided from May 17, 2022, to July 13, 2022 
 
You asked the Plan to waive the coinsurance for out-of-network specialist office visits. You say that you 
disagree with the coinsurance. 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 50% 
coinsurance for out-of-network physician/practitioner services/Medicare-covered specialist visit.  
 
You have been asked to pay a 50% coinsurance for out-of-network specialist office visits. The total allowed 
amount per visit is $125.38. You are being asked to pay $376.14 ($125.38 x 3 visits = $376.14). You are 
responsible for to pay 50% of the total amount which is $188.07 ($376.14 x 50% = $188.07). This item/service 
falls within the out-of-network physician/practitioner services/Medicare-covered specialist visit 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 out-of-network specialist office visits provided 
from May 17, 2022, to July 13, 2022
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not met 
the step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary in this case. Our physician reviewer found there is documentation of 
trial and failure of Boniva, but there is no indication that the enrollee has tried and failed zoledronic acid. There 
is no indication that zoledronic acid would likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
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 it is not safe for the enrollee to be alone. You also 
say the enrollee is very unstable on his feet and needs physical therapy to strengthen him, in addition to other 
services to assist in his cognitive abilities. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare guidelines for services in a skilled nursing facility (SNF). 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 pay for a diagnostic reading provided on July 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for diagnostic reading. You say that the services were not authorized, and the 
anesthesiologist should not be penalized. The Plan denied your request. The Plan says there was no prior 
authorization on file and the provider was out of 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 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 a diagnostic reading provided on July 3, 2022, by 
an out-of-network (OON) provider.