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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility. 
 
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 enrollee was admitted for diarrhea, dehydration, and renal failure. The enrollee's medical problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation 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 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: 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 the enrollee does not have a caregiver that is able to 
meet their needs for a home discharge. The enrollee has limited resources to continue treatment plan in the 
home setting. The Plan denied your request. The Plan says the SNF care is not medically necessary, and the 
enrollee's needs can be met with part-time nursing care or therapies or outpatient therapy or home health care. 
 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs and a 
diagnostic colonoscopy provided on May 16, 2022 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs and a diagnostic 
colonoscopy. 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 20% 
coinsurance and a 20% coinsurance for Medicare Part B prescription drugs and an outpatient hospital 
services/diagnostic colonoscopy.  You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a 20% coinsurance 
for a diagnostic colonoscopy. The total allowed amount for the injection is $169.74. you are being asked to pay 
$33.95 ($169.74 x 20% = $33.95). The total allowed amount for the colonoscopy is $779.27. You are being 
asked to pay $155.85 ($779.27 x 20% = $155.85). The total amount you are being asked to pay $189.80 
($33.95 + $155.85 = $189.80). This item/service falls within the Medicare Part B prescription drugs and 
outpatient hospital services/diagnostic colonoscopy 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 Medicare Part B prescription drugs and a diagnostic colonoscopy provided on May 16, 2022
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Visco-3. 
 
You asked the Plan to pre-approve Visco-3. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Gel One and Synvisc. 
 
 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 Visco-3. Our physician reviewer found 
that the enrollee has osteoarthritis of the knee. The requested medication is a new start. The Plan requires a trial 
of Gel One and Synvisc before they will approve the requested drug. The provided records do not indicate that 
the enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step one alternative.  
The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Visco-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Visco-3.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can safely receive the care they need in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services available at the LTACH that the enrollee requires that are 
not available at the current health care setting. The Plan has approved ongoing care in the current acute care 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 14-day continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre 14-day CGM. You say that the enrollee needs this medical 
equipment. The Plan denied your request. The Plan says a CGM is not covered for an enrollee who is not on 
insulin. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre 14-day CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre 14-day continuous glucose monitor (CGM).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the residential treatment services received March 14, 2022, to April 8, 2022.
You asked the Plan to pay for the residential treatment services. You say that you feel these services received were medically necessary. The Plan denied your request. The Plan says that the services received are not a covered benefit.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for mental health treatment. Residential treatment is not covered. Therefore, we decided that the Plan does not have to pay for the residential treatment services received March 14, 2022, to April 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an oral appliance purchased on September 23, 2021, to treat obstructive sleep apnea.
You asked the Plan to pay for this purchase. You say that you needed this appliance while you were on the waiting list for a Continuous positive airway pressure (CPAP) device. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional clarification on coverage.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of oral appliance. Based on the medical records provided you did not meet all of the criteria required for coverage for the oral appliance you purchased. Therefore, we decided that the Plan does not have to pay for an oral appliance purchased on September 23, 2021, to treat obstructive sleep apnea.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
April 12, 2022.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you do not feel the provider
rendered this service. The Plan denied your request. The Plan says your benefit for the requested item or
service has already been exhausted.
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, certain limitations apply. The record
shows your benefit for the requested item or service was exhausted on date of service August 27, 2021.
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150)
provided on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services (93000 and 99214) provided on June 4, 2021.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that they are not the primary payer for this service.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the physician services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the physician services (93000 and 99214) provided on June 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to adjust the payment for surgical services provided on March 9, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid as billed. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan notes that they paid the fee schedule amount and applied the appropriate reduction to codes 27535, 29879 and 29881 (100%, 50%, 50%, 50%, 50%, and by report) based on Medicare billing guidelines. The Plan notes the following: Line 1 27535 (MULT PROC 2) is paid at full (100%) facility price. Line 2 29879 (MULT PROC 2) is paid with MULT PROC 2 at half (50%) facility price. Line 3 29881 (MULT PROC 3) is paid based on the difference between the next highest paid endoscopy and base endoscopy and MULT PROC 2 at half (50%) facility price. Line 4 76000 has no endobase and is paid in full (100%) facility price.
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, the guidelines applied by the original Maximus review were incorrect. Based on the claim submitted and the medical records, this claim was processed appropriately. Therefore, we decided that the Plan does not have to pay for surgical services provided to the enrollee on March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse the recoupment of skilled nursing facility services for dates of service October 24, 2020, to October 31, 2020.
You asked the Plan to repay the recoupment or adjustments made to this claim. You say that the Plan should pay this claim as billed. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial because medical records were not submitted with the case file. The Plan requested a reopen and submitted the required medical records. The Plan notes that there is no dispute that the services were required. The Plan states a claim audit found the provider reported skilled services with the incorrect PDPM Health Insurance Prospective Payment System (HIPPS) Score. This score represents a specific set of patient characteristics (or case-mix groups) at a defined moment in time and are required to be reported on claims to insurers and permit insurers to determine appropriate payment for quality skilled care. Based on the scores in the guidelines, the following changes were made to the coding of this claim: The first alpha numeric character of the PDPM represents the physical therapy or occupational therapy. With a usual function score of UTD the default level of the hierarchy is applied, which is appropriately coded as "P", rather than "O" which was billed by the provider. The third alpha numeric character of the PDPM represents the Nursing component. The case-mix hierarchy is applied, which is appropriately coded as "Y" rather than "X" that was billed by the provider. The fourth alpha numeric character of the PDPM represents the NTA component. The total NTA points score changed from 1 to 0, which changes the fourth alphanumeric character from "E" to "F". After consideration of the medical records received for the appeal, it is clear that the medical records support our decision to revise the MDS score of as outlined in Medicare guidelines, which results in a change from the provider billed PDPM of OHXE1 times 8 days to the Plan adjusted PDPM to PHYF1 x 8 days.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the medical records show a discrepancy between the PDPM codes reported and the actual scored services provided. Medicare billing rules for coverage of this claim as originally billed were not met. Therefore, we decided that the Plan does not have to reimburse the recoupment for skilled nursing facility services provided from October 24, 2020 to October 31, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service July 25, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that this was not a bundled charge. The Plan 
denied your request. The Plan says payment for code 76700 is bundled into payment for code 93976. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76700 billed for date of service July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified oral surgery procedure on tooth #23 
(D7999). 
 
You asked the Plan to pre-approve the oral surgery procedure. You say that you disagree with the denial of the 
requested dental services. The Plan denied your request. The Plan says an unspecified oral surgery procedure 
(D7999) is not covered by your dental benefits. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
unspecified oral surgery procedure on tooth #23 (D7999).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on January 
30, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. 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 $275 
copayment for ambulance services.  
 
You have been asked to pay a $275 copayment for ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on January 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the oral evaluation (D0120), the radiographic images 
(D0330), the cleaning (D1110), reline of complete upper denture (D5750) and to pay for sales tax (D9985) 
provided by an out-of-network provider on August 9, 2022, and September 8, 2022. 
 
You asked the Plan to pay more for the oral evaluation, the radiographic images, the cleaning, reline of 
complete upper denture and to pay for sales tax. You say that the provider told you that they accepted your 
insurance, and you did not know they were an out-of-network provider. The Plan denied your request. The Plan 
says you are responsible for any charged amount above the Plans cost-sharing amount when your services are 
received from an out-of-network provider. Also, the denial of payment for the sales tax is correct, because it is 
not covered by 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
sales tax is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pay more for the oral evaluation (D0120), the radiographic images (D0330), the cleaning (D1110), reline of 
complete upper denture (D5750) and to pay for sales tax (D9985) provided by an out-of-network provider on 
August 9, 2022, and September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 22, 2021. 
 
You asked the Plan to pay for an office visit. You say that you are appealing this denial with supporting 
records. The Plan denied your request. The Plan says the enrollee must receive care from a network provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an office visit have been met. The case 
file included an invalid Waiver of Liability (WOL). The Plans attempt to obtain a valid WOL was 
unsuccessful.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for an office visit provided on July 22, 2021.