Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 additional speech therapy visits. 
 
You asked the Plan to pre-approve 14 additional speech therapy visits. You say that these additional therapy 
services are medically necessary. The Plan denied your request. The Plan says the provided records do not 
support the request for extended treatment without reassessment of progress. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 14 additional speech therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the additional requested therapy generally is not 
accepted as specific and effective therapy for the patients condition beyond what was approved by the health 
plan. The enrollee has had prior therapy and the documentation does not reveal that they require the unique 
skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist beyond what was already 
approved. The requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
the patient's current condition or to prevent or slow further deterioration. The patient has been approved for 
sufficient therapy to be able to transition to an independent home exercise program. His remaining deficits do 
not require ongoing skilled therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 14 additional speech therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 14 additional speech therapy visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from June 29, 2021, 
to July 21, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says the non-contracted provider did not 
submit the RAP claim for dates of service June 29, 2021, to July 21, 2021, until August 16, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have 
to pay for the home health care services provided from June 29, 2021, to July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the rendering physician is a hospitalist and depends 
on the hospital staff to obtain proper authorization. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on February 15, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The provided 
documentation does not reveal an unstable condition or other factor that would warrant inpatient services for 
this lower risk elective surgery. There is no suggestion that the patient would require hospital services that 
would likely cross 2 midnights following this planned procedure. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for an overpayment for the out-of-pocket maximum received from 
February 15, 2021, to February 26, 2021. 
 
You asked the Plan to pay for the services. You say that you have met your out of pocket maximum for the 
year and would like a refund. The Plan denied your request. The Plan says that they were unable to make a 
decision in the allotted timeframe. 
 
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 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. The plan has not refuted your assertion that you have paid the out-of-pocket 
maximum for the year. The plan has not substantiated their denial in a meaningful way in this case. It does 
appear that you have met your out-of-pocket maximum for the year, and you should not have to pay more than 
Therefore, we decided that the Plan has to pay for an overpayment for the out-of-pocket maximum received 
from February 15, 2021, to February 26, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines.  Therefore, the requested bone marrow aspirate in the setting of spinal fusion, in this case, is not medically reasonable or necessary. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the yellow fever vaccine provided on October 13, 2021. 
 
You asked the Plan to pay for the yellow fever vaccine. You say that you got this vaccine because you were 
traveling to Kenya, which was required. You feel that this vaccine should be covered because it avoided much 
larger expenses if you had contracted yellow fever and needed treatment. The Plan denied your request. The 
Plan says this vaccination is not covered by Medicare. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the yellow fever 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the yellow fever 
vaccine. Therefore, we decided that the Plan does not have to pay for the yellow fever vaccine provided on 
October 13, 2021.  
 
Benefits for the yellow fever vaccine may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve an epidural steroid injection (ESI). You say that an epidural steroid injection 
is medically necessary. The Plan denied your request. The Plan says an epidural steroid injection does not meet 
the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 an epidural steroid injection (ESI). Our 
reviewer says that an epidural steroid injection (ESI) is not medically necessary. Our physician reviewer found 
in this case the enrollee had a prior ESI on April 26, 2022. An office visit on May 2, 2022 documented that the 
enrollee had 7/10 pain. However, at that visit, the enrollee related a 50% reduction in pain for 1 week. The 
LCD for this entity requires at least 50% pain relief for at least 3 months. The enrollee was scheduled for a 3 
month visit but 7/10 pain at 1 week is consistent with a failure of an ESI.  The review has determined that the 
requested epidural steroid injection does not meet the Medicare LCD coverage criteria. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection (ESI) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an epidural steroid injection (ESI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for maxillary partial dentures (D5211) 
provided on April 14, 2022. 
 
You asked the Plan to waive the coinsurance for partial dentures. You say that you feel that you should not 
have to pay for the dentures. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 50% 
coinsurance for in-network partial dentures.  You have been asked to pay $420.32, which is 50% coinsurance 
of the allowed amount for partial dentures 
($840.65 allowed amount x 50% coinsurance = $420.32). Partial dentures fall within the Dental 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 coinsurance for maxillary partial dentures 
(D5211) provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a crown on tooth #30 (D2740) provided 
on June 1, 2021. 
 
You asked the Plan to waive the coinsurance for a crown. You say that you would like to be reimbursed since 
you need to have the crown re-done. The Plan denied your request. The Plan says that you have been charged 
the correct cost sharing amount. 
 
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 50% coinsurance for supplemental comprehensive dental services, including crowns.  
 
You have been asked to pay $307.50, which is 50% coinsurance of the allowed amount for a crown ($615 
allowed amount x 50% coinsurance = $307.50). A crown falls within the Dental 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 coinsurance for a crown on tooth #30 (D2740) provided on June 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that this is medically reasonable for the 
enrollee's condition. The Plan denied your request. The Plan says the clinical value and effectiveness of bone 
marrow aspirate have not been demonstrated in the peer-reviewed literature. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested one marrow aspirate remains experimental when used as bone graft 
material. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the requested bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81162). 
 
You asked the Plan to pre-approve the genetic testing. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA1/BRCA2 genetic testing is not reasonable 
and necessary, thus it is non-covered, for individuals with no personal history of breast, ovarian, fallopian tube, 
primary peritoneal, pancreatic, or prostate cancer. Such testing is considered screening and is excluded by 
Medicare statute. 
 
We looked at the file and Medicare rules. The record shows no personal history of breast, ovarian, fallopian 
tube, primary peritoneal, pancreatic, or prostate cancer. Based on this information, we decided that Medicare 
rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve genetic testing (81162).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a wound therapy pump and disposable 
canister provided on March 11, 2022. 
 
You asked the Plan to reduce the coinsurance for the wound therapy pump and disposable canister. You say 
that you were informed the cost would only be about $77 total. The Plan denied your request. The Plan says the 
correct coinsurance was applied. 
 
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 durable medical equipment (DME), including wound therapy supplies. 
 
Item Allowed Amount 20% Coinsurance 
Disposable Canister (A7000) $251.40 $50.28 
Wound Therapy Pump (E2402) $1,759.37 $351.87 
Total:  $402.15 You have been asked to pay a total of $402.15, which is 20% of the allowed amount for the wound therapy 
pump and disposable canister. The wound therapy pump and disposable canister fall within the Durable 
Medical Equipment (DME) and Related 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 reduce the 
coinsurance for a wound therapy pump and disposable canister provided on March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ophthalmology visit provided on April 
1, 2022. 
 
You asked the Plan to waive the copayment for an ophthalmology visit. You say that you should not have a 
copayment for this visit. 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 $30 
copayment for other Medicare-covered vision services.  
 
You have been asked to pay a $30 copayment for an ophthalmology visit. An ophthalmology visit falls within 
the Other Medicare-Covered Vision 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 ophthalmology visit provided on April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $40 copayment charged for a diagnostic eye exam
provided on January 5, 2022.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The
Plan denied your request. The Plan says this copayment was charged based on the Plan contract and the claim
submitted by your provider. Maximus overturned the Plans denial because the incorrect Evidence of Coverage
was sent for review. The Plan requested a reopen and provided the required contract.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay $40 copayment for
diagnostic vision exams.
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 charged for a diagnostic eye exam provided on January 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share for outpatient services provided on
June 30, 2021, and July 14, 2021.
You asked the Plan to waive this cost share. You say that you think you are being double billed. The Plan
denied your request. The Plan says these services were billed based on the records provided and the Plan
contract agreement. Maximus overturned the Plans denial for insufficient billing information in the case file.
The Plan requested a reopen and provided documentation to show these services were indeed provided on June
30, 2021, and July 14, 2021.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you have a cost share for each service provided as listed in the Plan contract. Documentation
has been provided to show these services were rendered. 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 or
reduce the cost share charged for outpatient services provided on June 30, 2021, and July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consult with a Periodontist. 
 
You asked the Plan to pre-approve consult with a Periodontist. You say that you need this service because the 
pain is so severe you cannot chew or eat. The Plan denied your request. The Plan says dental services are 
covered when performed by a participating general dentist. 
 
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 
consult with a Periodontist.