Persius/hicric huggingface dataset:
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 benefit from long-
term acute care due to their medical complexity. The Plan denied your request. The Plan says the current acute 
care hospital can provide acute care services until the member's condition allows transfer to an alternate level 
of care, such as skilled nursing facility, acute inpatient rehabilitation, home health care, nursing home, or home. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing or skilled therapy needs. 
Given the potential iatrogenic nature of his decline, a period of skilled therapy is reasonable to assess the true 
nature of the enrollees potential. Daily skilled services are required to establish a maintenance program or to 
prevent deterioration of the enrollees condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of 
authorization for long term acute care hospital admission. The Plan denied your request. The Plan says based 
on Medicare guidelines, the long-term acute care hospital services you are requesting do not meet the 
requirements for approval. 
 
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 the enrollee was admitted to the hospital on September 16, 2022, with pain in the 
residual limb. The enrollee was found to have osteomyelitis requiring intravenous antibiotics. The enrollee also 
has wound vacuums to bother lower extremities. There is no documentation provided indicating medical 
necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care 
hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
where they are currently receiving 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the physician service. You say that you would like to continue care with this 
provider due to established trust and care with provider. The Plan denied your request. The Plan says the 
services can be safely continued in-network. 
 
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 an office visit to be provided by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from March 15, 2022, to 
March 31, 2022. 
 
You asked the Plan to pay for self-administered drugs. The Plan denied your request. The Plan says Medicare 
Part B generally does not pay for drugs that are usually self-administered by the patients who take them. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from March 15, 2022, to March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unlisted dentoalveolar implant (41899) to be 
provided by a network provider. 
 
You asked the Plan to pre-approve the unlisted dentoalveolar implant (41899). You say that you say that your 
diagnosed jaw issue prevents you from using your dentures. You say you run the risk of choking because you 
cannot properly chew food. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 unlisted dentoalveolar implant 
(41899) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve the unlisted dentoalveolar implant (41899) to be provided by a network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Granix for the enrollee. 
 
You asked the Plan to pre-approve Granix. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred drugs would likely be less effective, and/or 
cause adverse effects for the enrollee. 
 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 Granix. Our reviewer says that Granix 
is not medically reasonable and necessary. The enrollee has not tried and failed Nivestym and Zarxio. The 
Plan's required drugs would not likely be less effective and/or likely have adverse effects for the enrollee. Our 
physician reviewer found that the enrollee's condition does not meet step therapy criteria for Granix. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Granix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Granix for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue barrier (D4266) tooth #3, sinus 
augmentation (D7951), intravenous sedation, each subsequent 15 minutes (D9243 x3), intravenous sedation 
first 15 min (D9239) and surgical removal of erupted tooth (D7210 x2) tooth #14 and #15. 
 
You asked the Plan to pre-approve dental services. You say that the enrollee needs the dental services 
requested. The Plan denied your request. The Plan says this service is not covered under your 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
guided tissue barrier (D4266) tooth #3, sinus augmentation (D7951), intravenous sedation, each subsequent 15 
minutes (D9243 x3), intravenous sedation first 15 min (D9239) and surgical removal of erupted tooth (D7210 
x2) tooth #14 and #15.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no documentation that the enrollee requires the services on an inpatient basis, 
only in a SNF setting. Records do not support that the services in a long-term care facility on a part time basis 
are not appropriate in this case. 
 
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 SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires SNF services to improve 
function. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF care and can 
be treated in a lower level of care such as home health. 
 
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 daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in 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 SNF care.
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 you are requesting LTACH services for 
the enrollee. The Plan denied your request. The Plan says LTACH is not medically necessary currently. The 
Plan will continue to cover acute level care at the current hospital as long as it is medically necessary. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to waive the $25 specialist copayment for a clinic visit provided on January
6, 2022.
You asked the Plan to waive this cost share. You say that you saw your primary care doctor, not a specialist.
The Plan denied your request. The Plan says this claim was submitted as a specialist visit. Maximus overturned
the Plans denial for a lack of medical records in the file. The Plan requested a reopen and provided the medical
record documentation to show this was a specialist visit, not a primary care visit.
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 $25 copayment for
specialist visits. Based on the records provided, 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 the Plan does not have to the $25 copayment for a specialist clinic visit provided on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 6, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on May 6, 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 the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial to cover 
admission to a long term acute care hospital. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
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 the enrollee was admitted with acute on chronic respiratory failure in the setting of 
sepsis secondary to abdominal wall cellulitis from gastrostomy tube displacement, pseudomonas pneumonia 
and enterococcal faecalis bacteremia. The record indicates that the enrollee remains critically ill with 
respiratory failure and severe hypoxic ischemic encephalopathy. The record also indicates the enrollee still 
requires acute care services. The enrollee does not require services at the LTACH that are not available at the 
current facility where they are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture provided on June 1, 2020.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says these services were not a covered benefit under your 2020 contract. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not follow the Plan contract rules or the Medicare billing rules. The Plan states the out of network provider billed this claim without the appropriate revenue codes or description of the service. The Plan Medical Director approved the services based on the incorrect EOC benefit. According to your contractual 2020 Evidence of Coverage pages 96 - 98, Acupuncture Services is never covered under any condition.
The Plan is correct in this case. The Plan must follow Medicare rules. Typically, the rules stated that acupuncture services were not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for chronic low back pain meeting certain requirements. The issue is the contract with the Plan did not cover acupuncture and while Medicare provided limited coverage as of January 21, 2020, your out of network provided neglected to submit and appropriate claim for services that would demonstrate you met those criteria. Had you seen a network provider, the Plan would have had to intercede on your behalf for a corrected claim. The Plan is not required to do so with out of network providers. Therefore, we decided that the Plan does not have to pay for acupuncture provided on June 1, 2020.
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 you are appealing the denial of authorization for 
acute inpatient rehabilitation admission. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they 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 not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the therapy notes indicate fatigue and decreased endurance. There are no 
complex nursing or rehabilitation needs. While the enrollee has a need for physical or occupational therapy, 
there is no documentation of a need for an intensive rehabilitation program. 
 
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.