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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the patient can be managed 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 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 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $177.14 copayment for outpatient surgery performed on 
February 8, 2022. 
 
You asked the Plan to waive the $177.14 copayment for outpatient surgery performed on February 8, 2022. 
You say that you should not have to pay this because this procedure was not performed in a hospital setting. 
The Plan denied your request. The Plan says you are responsible for a $177.14 copayment. 
 
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 Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
 
 
 
 
  
You have been asked to pay a $177.14 copayment for outpatient surgery performed on February 8, 2022. 
Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers benefit category. Your contract with the Plan clearly says that you 
must pay a $295 copayment for in-network outpatient surgery. However, you have only been asked to pay 
$177.14, which is less than the $295 copayment amount. 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 $177.14 
copayment for outpatient surgery performed on February 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the records provided support the need 
for the requested spinal cord stimulator. You say that Medtronic's documentation shows that it is okay to have a 
pump and a stimulator when they are a minimum of 20 centimeters away from each other The Plan denied your 
request. The Plan says the enrollee currently has a pump in place and Medicare rules don't allow both, as 
having an electrical pain device may potentially change the dose in the pain pump. 
 
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 a spinal cord stimulator. Our reviewer 
says that a spinal cord stimulator is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has post-laminectomy syndrome. He has a functioning intra-thecal pump 
with a current mixture of Hydromorphone, clonidine and baclofen. The requested a spinal cord stimulator is 
contraindicated with other implanted programmable devices. 
 
 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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have exceeded your benefit limit for 
routine transportation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way transportation trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee brace represented by code L1852. 
 
You asked the Plan to pre-approve the knee brace. You say that the records provided support the need for the 
requested orthosis. The Plan denied your request. The Plan says the guidelines for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the type of knee brace represented by code L1852 is 
covered when the enrollee has had recent injury or a surgical procedure on the knee(s). Medicare rules also say 
that this type of knee brace is covered when the enrollee is both ambulatory and having knee instability due to a 
covered condition.  
 
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 knee brace. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee has not had recent injury 
or a surgical procedure on the knee. The medical records from the orthopedic and physical therapy exams do 
not demonstrate that the enrollee has knee instability. 
 
 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 knee brace have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee brace represented by code L1852.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $40 copayment for a walk-in clinic visit on February 22, 
2022. 
 
You asked the Plan to waive the $40 copayment for a walk-in clinic visit on February 22, 2022. You say that 
you should not have to pay this because you were never told there would be a charge for this service. The Plan 
denied your request. The Plan says you must pay a $40 copayment for each walk-in clinic visit. 
 
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 $40 
copayment for Urgently Needed Services.  
 
 
 
 
 
 
 You have been asked to pay a $40 copayment for a walk-in clinic visit. A walk-in clinic visits falls within the 
Urgently Needed 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 $40 copayment for a walk-
in clinic visit on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral prescription drug (J8499) provided on January 6, 2022. 
 
You asked the Plan to pay for the oral prescription drug. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim is not eligible for payment 
based on billing guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, code J8499 has a Payment Status Indicator of E1 
indicating that it is not paid by Medicare when submitted on outpatient claims. Based on this information, we 
decided that Medicare rules for coverage of the oral prescription drug have not been met. Therefore, we 
decided that the Plan does not have to pay for the oral prescription drug (J8499) provided on January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hand orthosis you received on July 27, 2020. 
 
You asked the Plan to pay for the hand orthosis. You say that this should be covered because it was needed as 
the result of an emergency. The Plan denied your request. The Plan says this item was billed with an incorrect 
Place of Service. The Plan must follow Medicare rules. Medicare rules say that for durable medical 
equipment/orthotics, providers must bill the place of service where the item will be used. This is usually the 
patient's home.  In this case, the provider billed with a Place of Service of 11, which is an office setting.  This is 
not an appropriate Place of Service with this item.  The Plan has contacted this provider to advise them that 
they billed this incorrectly. Until the provider submits a corrected claim, this is not payable. Therefore, we 
decided that the Plan does not have to pay for the hand orthosis you received on July 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided on January 1, 2022.
You asked the Plan to pay for self-administered drugs under Medicare Part B. You say that the Plan should pay
this bill. The Plan denied your request. The Plan says self-administered drugs, even those provided by a
facility, must be submitted to Medicare Part D for payment. Maximus overturned the Plans denial for a lack of
claim information in the file to confirm self-administered drugs were provided. The Plan requested a reopen
and submitted the required information for review.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs provided are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided
on January 1, 2022.
Payment for this claim may be available under Medicare Part D. Please contact your Medicare Part D carrier
for further information.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency medical services provided to the enrollee on
August 9, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans
denial for insufficient claim information. The Plan requested a reopen and provided additional information. The
Plan states code 99285 was denied for no records submitted. Since the Plans denial records were received and
procedure code 99285 was processed and paid on February 23, 2022. A copy of the paid Provider Remittance
Advice was submitted with the reopen.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. We now find that code 99285 was paid, and that part of the review is now dismissed.
Code 99503 has a status indicator of B. This means that payment for this service is always bundled into the
payment for another service or procedure. Therefore, we decided that the Plan does not have to pay for
emergency medical services provided to the enrollee on August 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on February 8, 2022.
You asked the Plan to pay for the compression stockings. You say that these stockings are medically necessary for you. The Plan denied your request. The Plan says you did not receive stockings that are covered by Medicare and the stockings were not billed with a diagnosis of venous stasis ulcers.
The Plan must follow Medicare rules. Medicare rules say that compression stockings are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The claim submitted does not show that you have open venous stasis ulcers or a qualifying wound. The only diagnosis billed for these stockings is lymphedema, which is not a covered diagnosis. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2750) for tooth #15.

You asked the Plan to pre-approve a crown (D2750) for tooth #15. The Plan denied your request. The Plan says that the x-rays provided show a crown is not needed to fix the enrollee's tooth.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the Independent Review Entity (IRE) information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, digital quality x-rays were not provided with this case. We asked for these x-rays, but they were not received. Without digital quality x-rays we cannot determine if a crown for tooth #15 is not medically necessary. Therefore, we decided that the Plan has to pre-approve a crown (D2750) for tooth #15. 

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 dental services coded as D0274 Bitewings, four radiographic
images, provided on November 3, 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 this benefit was exhausted. Maximus overturned the Plans denial for a
lack of claim information to show this service was previously paid. The Plan requested a reopen and provided
documentation to show the service had been rendered on May 5, 2021.
The Plan is correct in this case. Medicare 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. The record shows this
imaging benefit was exhausted on May 5, 2021. Therefore, we decided that the Plan does not have to pay for
dental services coded as D0274 Bitewings, four radiographic images, provided on November 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for mammography services billed for March 22, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial stating the
medical records support the services billed were necessary. The Plan requested a reopen and stated that the
issue was not medical necessity but that the claim was previously paid. The Plan requested a reopen and
provided additional claim information. The Plan shows that this is an administrative determination for coding
errors. The records show the enrollee had a mammography with tomosynthesis on March 22, 2021. The
submitted documentation supports 1 (one) unit each of 77066-TC and G0279-TC, which were previously
approved and paid to the same provider. There is no additional documentation supporting additional studies
were performed. The reports submitted are duplicates of each other.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case we show duplicate claims were submitted. Medicare rules for coverage of
these services have not been met. Therefore, we decided that the Plan does not have to pay for mammography
services provided to the enrollee on March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the crowns - porcelain/ceramic 
(D2740) provided January 14, 2022. 
 
You asked the Plan to provide additional payment for the crowns. You say that the work started in 2021, and 
you feel your claims should be applied to your 2021 dental allowance. The Plan denied your request. The Plan 
says the cost sharing has applied correctly. 
 
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 crowns 
with 20% coinsurance up to your $2,000 dental allowance. 
 
We looked at the file and Medicare rules. In this case the services were provided in 2022. You have been asked 
to pay 20% coinsurance for the services. Additionally, you paid more for the final crown because you exceeded 
your dental maximum allowance. You are responsible for the cost above this allowance.  Therefore, we decided 
that the Plan does not have to provide additional payment for the crowns - porcelain/ceramic (D2740) provided 
January 14, 2022.   
Your complaint about billing concerns and which years benefits services were applied to 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) services.
You asked the Plan to provide coverage for SNF services. You say that at the time of the appeal, skilled
nursing facility services were medically necessary. 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 coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services.
The Maximus Physician Reviewer determined that while you did not have daily skilled nursing needs, you did
have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled
professional therapist, and you were functioning below baseline. The documentation had not established that a
new, lower level of function had been reached. Daily skilled services were required to establish a maintenance
program and/or to prevent deterioration of your condition. The Plan requested a reopen and argued that you
were ambulating 160 feet with a walker, and all mobility and transfers were documented at contact guard
assistance. You lived with adult children and had a safe discharge disposition.
The medical records show that you presented to the hospital on March 4, 2022, with altered mental status.
On March 9, 2022, you walked 25 feet with a rolling walker. The physical therapy notes dated March 10, 2022,
state you ambulated 160 feet with a rolling walker. You had steady gait and the discharge recommendation was
home health care with outpatient therapy. Our Medical Director has concluded that the Plan is correct in this
case. The documentation does not support that, at the time of the medical review, you required skilled services
daily on an inpatient basis in a skilled nursing facility 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 services were not met at the time of the appeal. Therefore, we decided that
the Plan does not have to provide coverage for skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206 and 81292) provided from 
September 6, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81206 and 81292) provided from September 6, 2021.