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 acute care and rehabilitation will allow you to 
return home in 2 weeks which is currently unlivable due to renovations to accommodate handicapped/elder 
living conditions. The Plan denied your request. The Plan says your records do not show you need to be seen 
by a rehabilitation doctor at least 3 times a week for evaluation of functional and medical goals and progress or 
that you need an intensive team for your 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 there is not a reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for tissue exam provided on June 17, 2022.

You asked the Plan to waive the deductible for laboratory services. You say that the fee for tissue exam should be part of the in-network colonoscopy. 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. Your contract with the Plan says that there is a 50% coinsurance, after your $750 plan deductible, for out-of-network Medicare-covered lab service.

The tissue exam you asked the Plan to waive the deductible for falls within the Outpatient diagnostic test and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which applies to out-of-network Outpatient diagnostic test and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time laboratory services was received on June 17, 2022. Therefore, we decided that the Plan does not have to waive the deductible for tissue exam provided on June 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to provide coverage for additional routine transportation trips for the 2022
benefit year.
You asked the Plan to provide coverage for additional routine transportation. You say that at the time of the
appeal additional transportation was necessary. The Plan denied your request. The Plan says at the time of the
appeal, you had exhausted the 24 one-way trips provided in the contract. Maximus overturned the Plans denial
because a Plan contract had not been submitted with the appeal. The Plan requested a reopen and provided a
copy of the required Plan contract.
The Plan is correct in this case. Medicare does not cover transport in a vehicle that is not an ambulance.
However, in 2022 the Plan offered a transportation benefit that exceeded Medicare coverage. For that reason,
the Plan's coverage rules apply in this case. The Plan covered a maximum of 24 one-way trips in 2022. At the
time of the appeal, this benefit was exhausted.
Exceptions are not made to supplemental benefits offered by the Plan that are not typically covered by
Medicare. Therefore, we decided that the Plan does not have to provide coverage for additional routine
transportation trips for the 2022 benefit year.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to waive the $40 copayment for the eye exam provided on July 7, 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 cost sharing was charged correctly. Maximus overturned the Plans
denial because a Plan contract was not submitted with case file for review. The Plan requested a reopen and
provided the required Plan 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 a $40 copayment for
diagnostic vision exams. Based on the claim submitted by your provider this was a diagnostic exam. 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 the eye exam provided on July 7, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says that based on Medicare guidelines, the IRF services requested do not meet 
the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the clinical documentation shows that the enrollee has active medical comorbidities and complex 
functional deficits (below the knee amputation is IRF compliant), thus the complexity of the enrollee's 
documented nursing, medical and rehabilitation needs would be expected to require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. Evaluating physical therapists and occupational 
therapists both recommend ongoing therapy 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you are unable to walk and need physical therapy. The Plan denied your request. The Plan says the medical records show your condition may be treated 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 there is not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker (E0149) and seat attachment, 
walker (E0156). 
 
You asked the Plan to pre-approve the heavy-duty walker. You say that the enrollee wants a bariatric walker 
because it would be more comfortable due to their weight. The Plan denied your request. The Plan says the 
enrollee's current standard rollator walker that was approved November 11, 2022, and the enrollee does not 
meet the weight criteria for a heavy-duty walker. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have walker, folding, wheeled, adjustable or fixed height (E0143) and seat attachment, 
walker (E0156). walker, folding, wheeled, adjustable or fixed height (E0143) and seat attachment, walker 
(E0156). A heavy-duty walker (E0148, E0149) is covered for beneficiaries who meet coverage criteria for a 
standard walker and who weigh more than 300 pounds. The records show the enrollees current weight is 268 pounds. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty walker (E0149) and 
seat attachment, walker (E0156).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want an inpatient rehabilitation facility in the 
immediate are where you had orthopedic surgery in case of any complications from your specialized procedure 
recently done. The Plan denied your request. The Plan says based on current information from your records, 
your therapy needs are neither complex nor intensive and your therapy needs can be safely fulfilled at 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 there a reasonable expectation that you 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on August 26, 2021. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5261, V5261) and a dispensing fee (V5160) 
provided on May 4, 2022. 
 
You asked the Plan to pay for hearing aids (V5261, V5261) and a dispensing fee (V5160). You say that the 
Plan told you the hearing aids should have been purchased from the Plan hearing vendor after the purchase had 
been made. The Plan denied your request. The Plan says they paid their maximum allowed for this benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased through the Plan's hearing vendor.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5261, V5261) and a dispensing fee (V5160) have not been met. Therefore, we 
decided that the Plan does not have to pay for hearing aids (V5261, V5261) and a dispensing fee (V5160) 
provided on May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment (G2067), and take-home 
supply of methadone (G2078) provided from June 9, 2022, to July 7, 2022. 
 
You asked the Plan to pay for the opioid treatment services. You say that the services should be covered. The 
Plan denied your request. The Plan says the provider in this case is not eligible to participate with Medicare. 
The Plan also says that payment cannot be made to a provider that does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the medication assisted treatment 
(G2067), and take-home supply of methadone (G2078) provided from June 9, 2022, to July 7, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on September 
27, 2022. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the patient was undergoing a 
major stressful event during this time.  She saw you prior to the change in insurance and had built rapport with 
you. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). The member had been in the plan for nearly two months at the time of these services. 
Also, no records from the patients primary care doctor were provided to show that an out-of-network mental 
health provider was medically necessary. Therefore, we decided that the Plan does not have to pay for the 
outpatient mental health services provided on September 27, 2022.
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. You say that the enrollee requires close daily oversight by a 
physician in an inpatient setting. You say that the enrollee has serious life-threatening constellation of acute 
medical problems that have left their functional status below their baseline. The Plan denied your request. The 
Plan says an IRF admission is not medically necessary, and the enrollee can get the services they need in other 
settings. 
 
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 has no active comorbidities and does not require continued inpatient 
hospitalization during rehabilitation for close medical motoring. 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee was in an ATV accident and has complex medical needs that cannot be met at a lower level of care. The Plan denied your request. The Plan says when ready to leave the hospital, the enrollee may safely receive this care in another setting, a Skilled Nursing Facility (SNF) or at home with home health services or outpatient setting if appropriate.

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 there are no services at the LTACH that the enrollee requires that are not already available and covered at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy to be provided by an out-of-network 
(OON) provider. 
You asked the Plan to pre-approve radiation therapy with an out-of-network provider. You say that you want to 
see the requested provider. The Plan denied your request. The Plan says the requested provider is out-of-
network. There are available providers in-network to provide the services. 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
radiation therapy to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the esophagogastroduodenoscopy (EGD 
test) provided on August 9, 2022, the soft tissue head and neck ultrasound provided on August 19, 2022, and 
the fine needle aspiration biopsy procedure provided on September 6, 2022. 
 
You asked the Plan to waive the copayments for the esophagogastroduodenoscopy, the soft tissue head and 
neck ultrasound, and the fine needle aspiration biopsy procedure. You say that you feel that these copayments 
are too high for these types of tests. 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 $200 
copayment for Medicare-covered outpatient hospital surgery services, and a $325 copayment for high-tech 
Medicare-covered diagnostic radiological services in a hospital setting. 
 
You have been asked to pay a $200 copayment for the esophagogastroduodenoscopy and a $200 copayment for 
the fine needle aspiration biopsy procedure. These items/services fall within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers benefit category benefit 
category. You have also been asked to pay a $61.33 copayment for the soft tissue head and neck ultrasound 
because the allowed amount for this service is less than $325. 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 
copayments for the esophagogastroduodenoscopy (EGD test) provided on August 9, 2022, the soft tissue head 
and neck ultrasound provided on August 19, 2022, and the fine needle aspiration biopsy procedure provided on 
September 6, 2022.