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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services he needs 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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care.  The patient was admitted for thoracolumbar surgery after a fall. The enrollees medical problems are stable. 
There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation 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. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transport provided on December 4, 2020.
You asked the Plan to pay for this transport. You say that this transport should be covered by the Plan because
you could not sit or stand when you were sent home from the hospital. Maximus overturned the denial for a lack of medical records. The Plan requested a reopen and provided additional information.
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 have prior authorization for
non-emergent transport and if you use an out of network provider, you are responsible for the bill. There is not
indication that you followed your Plan contract rules when obtaining transportation home from the hospital.
Therefore, we decided that the Plan does not have to pay for non-emergency transport provided on December
4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share applied to the deductible for podiatry services
provided on March 23, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says the deductible must be met prior to some services being covered by the
Plan. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply
the correct contract criteria.
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 must pay $35 copayment for podiatry services after the deductible is met. The $750
deductible was not met at the time of service. 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 cost share
applied to the deductible for podiatry services provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on August 17, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
 
 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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on August 17, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0812). 
 
You asked the Plan to pre-approve the power scooter. You say that the power scooter is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is primarily for use outside of the home. Although this item may be helpful, 
neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan 
does not have to pre-approve a power scooter (K0812).
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have any parental 
medication; complex wound care or nutrition given via a feeding tube. He is medically stable without any acute 
exacerbations of chronic medical problems. His physical function is at or near his baseline. The enrollee does 
not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can 
receive further rehab services at a lower level of care. Although further rehab services would be appropriate to 
improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care 
than a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additional reimbursement for eyewear provided on August
11,2021.
You asked the Plan to pay additional reimbursement. You say that the Plan should pay more of the cost of these
lenses. The Plan denied your request. The Plan says the full allowance for this benefit was applied. Maximus
overturned the Plans denial. The Plan requested a reopen stating that Maximus did not apply the correct
contract language. The Plan provided the required documentation to support the full benefit application.
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 there is a $200 maximum benefit for frames and lenses combined. The Plan provided
documentation to show the full benefit was applied. Therefore, we decided that the Plan does not have to pay
additional reimbursement for eyewear provided on August 11,2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary for the enrollee.
The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Keytruda
(Pembrolizumab). The Maximus Physician Reviewer determined that the enrollee had squamous cell
carcinoma of the lung with metastases to the brain. Given that the enrollee's cancer was then metastatic, and
there had not been prior immunotherapy, combination therapy was determined to be reasonable.
The Plan requested a reopen and argues that there had been progression during treatment with Imfinzi, which is
a PD-1/PD-L1 inhibitor. The plan also notes that the enrollee was not enrolled in a procedure specific registry
or a clinical trial for evidence development.
The medical records show the enrollee is a 58-year-old man who was diagnosed with squamous cell carcinoma
of the lung in October 2020. Chemoradiation with Carboplatin and Paclitaxel was completed in March 2021.
19 cycles of Durvalumab (Imfinzi) were administered for maintenance from March 24, 2021, through
November 14, 2021. In May 2021 the enrollee was diagnosed with metastatic disease to the cerebellum.
Gamma knife radiosurgery was performed. A craniotomy was performed in June 2021 and in July 2021 for a
pseudo meningocele. The enrollee has left hilar lymphadenopathy. The Plan is correct in this case. Durvalumab
is a monoclonal antibody that binds to PD-L1. The use of Keytruda is not supported in the NCCN guidelines
when there has been progression of advanced or metastatic squamous cell carcinoma while on previous
immunotherapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on May 25, 2021. 
 
You asked the Plan to pay for the drug testing. You say that the testing provided was medically necessary. The 
Plan denied your request. The Plan says that the ordering provider records do not show that the testing was 
ordered based on patient-specific elements. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the drug testing by a contract provider. The file does not show that the plan 
provided notice that the drug testing would not be covered. Under Medicare rules, this means the drug testing is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the drug testing provided 
on May 25, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from 
September 29, 2021, to September 30, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says an 
inpatient admission was not medically necessary. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from September 29, 2021, to  
September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids you purchased from Sam's Club, an out of 
network provider, on October 27, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you needed new hearing aids and this provider 
offered a fair price.  You said that you were under the impression that you could go to any hearing aid center. 
The Plan denied your request. The Plan says hearing aids are only covered when you purchase them from the 
designated network vendor. 
 
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 purchased from the Plan's designated hearing vendor. Based on this information, we 
decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the 
Plan does not have to pay for hearing aids you purchased from Sam's Club, an out of network provider, on 
October 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from May 27, 2021, to
May 29, 2021.
You asked the Plan to pay for inpatient care. You say that this claim should be paid. The Plan denied your
request. The Plan says while May 25, 2021, to May 27, 2021, was paid, services from May 27, 2021, to May
29, 2021, were denied. Maximus partially overturned the Plans denial in error. The Plan requested a reopen and
states Maximus made the same decision the Plan made.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. Our physician reviewer agreed with the Plan that as
of May 27, 2021, inpatient care was no longer required. Therefore, we decided that the Plan does not have to
pay for inpatient care provided to the enrollee from May 27, 2021, to May 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you have a prior relationship with the 
out-of-network provider and would like to continue to see them. The Plan denied your request. The Plan says 
they have adequate supply of in-network providers who can see the enrollee in a timely manner and that are 
within a short distance to the enrollee's residence. 
 
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 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing (G0483) provided on October 4, 
2021.  
You asked the Plan to pay for the definitive drug testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the record does not show screening test 
results which are positive or inconsistent with prescription medications, dosing schedules, or history and 
expected results. 
 
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 pay for the definitive drug testing. Our reviewer 
says that the enrollee did not meet criteria for this drug testing. Our physician reviewer found there was no 
abnormal or unexpected results from a screening test to require confirmation testing. There was no exceptional 
circumstance described in the notes to support this request. 
 
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 definitive drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the definitive drug testing (G0483) provided on October 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for services billed under codes 70554 and 93880.
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. The Plan
requested a reopen and provided additional information. The Plan stated that codes 70544 and 93880 denied
due to the associated diagnosis relationship criteria. These two codes were not submitted with a diagnosis code
which supports medical necessity according to Medicare guidelines.
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 claim and
diagnosis codes billed are not supported by the documentation submitted. Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for services provided to the enrollee on July 28, 2021,
and July 30, 2021 and billed under codes 70554 and 93880.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit (99204, 99213) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that your cardiologist has requested that 
you see the requested heart specialist, who can perform a less invasive procedure to correct the hole in your 
heart. You also say that he is not only the most skilled, but also highly qualified. The Plan denied your request. 
The Plan says a network provider is able to evaluate and consider whether to close your heart defect. 
 
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 a specialist office visit (99204, 99213) to be 
provided by an out-of-network (OON) provider.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not have any parental medication; 
complex wound care or nutrition given via a feeding tube. You are medically stable without any acute 
exacerbations of chronic medical problems. Your physical function is at or near your baseline. You do not 
require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can 
receive further rehab services at a lower level of care. Although further rehab services would be appropriate to 
improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care 
than a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.