Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine transportation service provided on August 3, 2022. 
 
You asked the Plan to pay for the routine transportation. You say that this provider is the only service locally 
that can transport you to and from your medical appointments.  The Plan denied your request. The Plan says the 
service was not provided by the Plan's designated provider. 
 
 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 Plans coverage rules apply in this 
case. The Plan covers routine transportation when this benefit is only available through the Plan's designated 
provider.  
 
We looked at your request, the records in the case file, and the rules. This service was not provided by the 
Plans designated routine transportation provider. Based on this information, we decided that the Plans rules 
for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to 
pay for routine transportation service provided on August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and pulp vitality tests 
(D0460) provided on September 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware there was a limitation on this 
service. The Plan denied your request. The Plan says these services have been processed correctly. 
 
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, certain limitations apply. The record 
shows your benefit for D0140 was exhausted on date of service July 26, 2022. D0460 is not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and pulp vitality 
tests (D0460) provided on September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
September 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel like this should be covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 3, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that your physician suggested that you 
should upgrade your CGM. The Plan denied your request. The Plan says the requested CGM is not considered 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Freestyle Libre 3 is not specified as a product 
that may be billed using code E2103.  
 
  We looked at the file and Medicare rules. The records show that you are requesting coverage of a non-
adjunctive CGM. As of January 1, 2023, the appropriate coding for a non-adjunctive CGM is E2103. The 
Freestyle Libre 3 is not specified as a product that may be billed using code E2103. Therefore, the Freestyle 
Libre 3 is not eligible for reimbursement. Based on this information, we decided that Medicare rules for 
coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a therapeutic continuous glucose monitor (CGM) and supplies.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic imaging provided on July 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for diagnostic imaging. You say that these services were medically necessary. The 
Plan denied your request. The Plan says 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 diagnostic imaging provided on July 7, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodic oral evaluation - established patient (D0120) 
and prophylaxis - adult (D1110) provided on September 26, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like to be reimbursed for 
charges incurred during this visit. The Plan denied your request. The Plan says you are responsible for any 
charged amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for periodic oral evaluation - established patient 
(D0120) and prophylaxis - adult (D1110) provided on September 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued acute inpatient psychiatric hospital care. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says these services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that 
the requested services are not medically necessary. Our physician reviewer found that the enrollee was involuntarily admitted to the state facility for acute 
inpatient psychiatric hospitalization on October 6, 2022 with Schizoaffective Disorder, Bipolar Type, and 
Generalized Anxiety Disorder. Based upon the review of the records provided, it was not expected that this 
enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, 
auditory or visual hallucinations, delusions, and was not showing any behavioral issues. It did not appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather 
than a lower level of care as he did not have dangerousness to self or others, perceptual disturbance including 
delusions, and auditory or visual hallucinations. The health plans denial of inpatient psychiatric services 
appears appropriate. This enrollee does not appear to require inpatient mental health treatment as he was not a 
danger to himself or others and was cooperative and compliant. It does not appear that active treatment was 
taking place. It does not appear that the services were reasonably expected to improve the enrollees condition 
or were for the purpose of a diagnosis. It does appear that the records were supervised and evaluated by a 
physician. Based upon the review of the records provided, the enrollee does not meet criteria for acute inpatient 
mental health treatment. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve continued acute inpatient psychiatric hospital care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 12, 2022, to 
June 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 12, 2022, to June 
10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pacemaker implantation. 
 
You asked the Plan to pre-approve pacemaker implantation. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that implanted permanent single chamber or dual chamber 
cardiac pacemakers are covered under certain circumstances. 
 
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 pacemaker implantation. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found while the enrollee has a 
evidence of pauses up to 2.8 seconds, there is no documentation of symptomatic bradycardia. As such, there is 
insufficient documentation to support the medical necessity for insertion of a pacemaker in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pacemaker implantation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve pacemaker implantation.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient psychiatric hospital care provided from  
September 15, 2022, through September 17, 2022. 
 
You asked the Plan to pay for these services. You say that the acute inpatient psychiatric hospital care provided 
was medically necessary for the enrollee. The Plan denied your request. The Plan says that the acute inpatient 
psychiatric hospital care provided was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was medically necessary for the enrollee. Our physician 
reviewer found that the enrollee was admitted for acute inpatient psychiatric hospitalization on September 15, 
2022 with Schizoaffective Disorder Bipolar Type, Cocaine Dependence with Withdrawal and Cluster B 
Personality Traits. Based upon the review of the records provided, it was expected that this enrollee would 
improve in a reasonable period of time as he did have dangerousness to self but not others, and auditory but no 
visual hallucinations. It did appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient level of care rather than a lower level of care as he did have dangerousness to self but not 
others, and auditory but no visual hallucinations. The health plans denial of inpatient psychiatric services 
appears inappropriate. This enrollee did appear to require inpatient mental health treatment as he was a danger 
to himself but not others. It did appear that active treatment was taking place. It did appear that the services 
were reasonably expected to improve the enrollees condition or were for the purpose of a diagnosis. It did 
appear that the records were supervised and evaluated by a physician. Based upon the review of the records 
provided, the enrollee did meet criteria for coverage of acute inpatient mental health treatment.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient psychiatric hospital care provided from September 15, 2022, through September 17, 2022.  
 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapies provided on September 22, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient therapies. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says the provider is out of network and the plan requires 
utilization of network providers when possible. 
 
 
 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 outpatient therapies provided on September 22, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair and a raised toilet seat. 
 
You asked the Plan to pre-approve a shower chair and toilet seat. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says these items are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs and raised toilet seats are not 
covered because they are not primarily medical in nature.  
 
While a shower chair and a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare 
offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a shower chair 
and a raised toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on August 18, 2022. 
 
You asked the Plan to pay for injections. You say that you did not know this provider was out of the network, 
and no one at the office told 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). Therefore, we decided that the Plan does not have to pay for injections provided on 
August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0120) and a cleaning (D1110) provided 
on August 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know the provider was an out-of-
network provider. The Plan denied your request. The Plan says the dental services were received from an out-
of-network provider and are not covered by your supplemental benefits. 
 
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. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an oral evaluation (D0120) and a cleaning (D1110) provided on August 12, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided the Plan does not have to pay for over the counter COVID-19 test purchased on February 1, 2022.
You asked the Plan to pay for this purchase. You say that the Plan should pay for this purchase. The Plan denied your request. Maximus overturned the Plans denial. The Plan requested a reopen and notes that neither Medicare nor the Plan covered this testing at the time of purchase.
The Plan is correct in this case. At the time of purchase neither your health Plan nor Medicare covered over the counter home testing kits. Therefore, we decided that the Plan does not have to pay for an over-the-counter COVID-19 test purchased on February 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal IRF care was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were 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 IRF services.
The Maximus Physician Reviewer determined that the requested IRF care was medically reasonable and necessary for this enrollee. The reviewer found the documentation showed that the enrollee had multiple active comorbidities and hospital complications and would be expected to continue to require close medical supervision. The Plan requested a reopen and argues intensive rehabilitative therapy generally consists of 3 hours of therapy per day 5 days a week. The enrollee must reasonably be expected to actively participate at the time of admission. The Plan states the medical records note several times that the enrollee refused therapy, was too tired for therapy or seems was not motivated to participate. The medical records show the enrollee was a then 85-year-old woman who suffered a subdural hematoma and an elbow injury in a fall, resulting in limited functional mobility, impaired balance, and impaired balance. Her medical history was notable for diabetes, hypertension, and atrial fibrillation. The enrollee reported leg fatigue around 40 feet into ambulation and insisted on returning to the recliner. On September 20, 2022, the enrollee reported severe fatigue, and deferred participation in physical therapy. The Plan is correct in this case. The documentation did not sufficiently support that the complexity of the enrollee's nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation did not support that the enrollee required at least 3 hours a day for 5 days a week, or 15 hours over 7 consecutive days, of therapy services, and that there was a reasonable expectation that the enrollee in this case would 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 provide coverage for 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 waive the copayment for the office visit on May 05, 2022.
You asked the Plan to waive the copayment for the office visit. You say that you want to appeal the amount being charged. 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 $45 copayment for each covered visit or consultation in an outpatient location with a specialist. You have been asked to pay a $45 copayment for the office visit. This item/service falls within the covered visit or consultation in an outpatient location with a specialist benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit on May 05, 2022.