Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for podiatry visits you had on April 5, 2021, 
and May 3, 2021. 
 
You asked the Plan to waive the copayments for the podiatry visits. You say that you had foot surgery on 
March 16, 2021.  You said that you were told there was no charge for these visits because they were follow-up 
visits. The Plan denied your request. The Plan says you were charged these copayments 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 $35 
copayment for podiatry visits.  
 
You have been asked to pay a $35 copayment for the podiatry visits. Medicare rules state that when you have a 
surgery, follow-up visits are included in the cost of the surgery during the approved post-operative period.  This 
post-operative period can be 0 days, 10 days, or 90 days, depending on the surgery.  The surgery you had has a 
10-day post-operative period.  Since these two podiatry visits were outside of this 10-day window, separate 
cost sharing can apply. 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 podiatry visits you had on April 
5, 2021, and May 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that Prolia is covered under Medicare Part D. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia for the enrollee.  
 
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a rollator walker (E1399) for the enrollee. 
 
You asked the Plan to pre-approve a rollator walker. You say that this walker is medically necessary. The Plan 
denied your request. The Plan says there were no medical records submitted that mention the need for or show 
medical necessity for the use of a rollator walker in the home. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for rollator walkers used in the 
home. No code was specified for this request. Code E1399 is a generic code and not the proper code for this 
request. The medical records are insufficient as they do not support the need for a rollator walker in the home.  
There is no indication the enrollee has tried and failed a standard walker in the home. Walkers of any type are 
not covered for use outside of the home. Based on your request and the information provided, Medicare 
coverage rules are not met. Therefore, we decided that the Plan does not have to pre-approve a rollator walker 
(E1399) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99072) provided on April 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee 
Schedule indicates that payment for covered services is always bundled into payment for other services not 
specified.  
 
We looked at the file and Medicare rules. Code 99072 is assigned a status indicator of "B" under the Physician 
Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for 
other services. No separate payment can be made for this service. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99072) provided on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an over-bed table (E0274). 
 
You asked the Plan to pre-approve an over-bed table. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the 
requested item is a convenience item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an over-bed table (E0274).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member's needs can be met at a less intense level of 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
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 this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health services or home with outpatient therapy. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgery of the thoracic and lumbar spine. Medical problems are stable. 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 medica l 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for cone beam CT image (D0383) provided by a participating
provider on June 16, 2021.
You asked the Plan to pay for cone beam CT image. You say that you were not aware that this would be that
expensive. The Plan denied your request. The Plan says these services are 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 Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone
beam CT image (D0383) provided by a participating provider on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for continuity of care with ophthalmology.
You asked the Plan to pre-approve the referral. You say that it is of utmost importance to continue care for management of the enrollee's glaucoma. The Plan denied your request. The Plan says there are multiple glaucoma specialists with the plan.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 referral. Our reviewer says that the requested referral is not medically reasonable or necessary. Our physician reviewer found the record indicates that the in network ophthalmologist planned a consultation to see if the plan had in network specialists that could provide the needed services. The plan has indicated they have in network glaucoma specialists. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for continuity of care with ophthalmology
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMems device.
You asked the Plan to pre-approve a CardioMems device. You say that this device is medically necessary. 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 a CardioMems
device. The Maximus Physician Reviewer determined that the requested services are considered medically
reasonable and necessary in this case. The Plan argues that you do not have a diagnosis of "NYHA class III
congestive heart failure (CHF"), and that the recent admissions for dyspnea were not clearly documented to be
due to heart failure alone. The Plan is correct in this case. The medical records in the case file do not contain a
diagnosis of "NYHA class III congestive heart failure". On April 19, 2021 the cardiologist documents that she
believes that the enrollee's dyspnea is related to restrictive heart disease, lung disease and obesity. The
available documentation in the case file is insufficient to demonstrate that the CardioMems device was
medically reasonable and necessary 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 a CardioMems device have
not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMems device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for acupuncture services with a licensed acupuncturist.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is must be provided by a Medicare-eligible provider.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the requested provider is not an eligible Medicare provider. Acupuncture must be provided by an eligible physician, nurse practitioner, or physician assistant. The provider is not one of these provider types. Therefore, we decided that the Plan does not have to pre-approve a referral for acupuncture services with a licensed acupuncturist.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on February 13, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the doctor advised no transport was needed to the hospital. The Plan denied your request. The Plan says if you refuse transport when an ambulance is dispatched, you will be responsible for the full cost of the service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 13, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on February 13, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Skilled nursing facility care provided from 
May 5, 2021, to May 17, 2021. 
 
You asked the Plan to waive the copayment for skilled nursing facility care. You say that the services were 
potentially deplorable and should be covered in full. The Plan denied your request. The Plan says the 
copayment applied correctly for the days you were admitted. 
 
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 $184 
copayment for days 12 through 100 for Skilled nursing facility (SNF) care.  

You have been asked to pay a $184 copayment per day for 12 days of SNF care (days 21-32 of the benefit 
period). The record shows that you received SNF care from February 25, 2021, through March 22, 2021 (19 
days). The 20th day of this benefit period was on May 5, 2021. The copayment for May 6, 2021, through May 
17, 2021, is $2,208 ($184 x 12 days = $2,208). 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 Skilled 
nursing facility care provided from May 5, 2021, to May 17, 2021.
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 she 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 abdominal pain and 
low back pain. No surgery was recommended. The enrollee's 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 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neurology services (95886 and 95909) provided on 
February 11, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the neurology services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 the neurology services (95886 and 95909) 
provided on February 11, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on July 7, 2021.  
 
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 you did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network 
physician services provided on July 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process
stabilization/distraction device at L4-L5 for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says the effectiveness of the requested procedure has not adequately been established, and
therefore it is investigational, which is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found these devices are experimental. More research is needed to show safety and efficacy.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device at L4-L5 for the
enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.