Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) to be provided by
a participating provider.
You asked the Plan to pre-approve a complete maxillary denture. You say that you accidentally threw out your
dentures. The Plan denied your request. The Plan says the benefit limit for a complete maxillary denture 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 Plan's coverage rules apply in this case. The Plan covers a complete
maxillary denture once every five calendar years.
We looked at the file and Medicare rules. Evidence was provided to show that D5110 was provided on
February 8, 2019. Based on this information, we decided that the Plan's rules for coverage of a complete
maxillary denture have already been met.
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) to be
provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is in bad shape and needs help. The Plan
denied your request. The Plan says your request for approval of an Inpatient Rehabilitation Facility (IRF)
admission does 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our
reviewer found that the enrollee does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, at an intensive rehabilitation therapy program. Our physician reviewer also
found that there is not a reasonable expectation that this individual 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound rendered on September 24, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 76705 (abdominal ultrasound) and 93976 (vascular study).
Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code
76705 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that
the Plan does not have to pay for the abdominal ultrasound rendered on September 24, 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.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehab to get back to his prior level
of function. The Plan denied your request. The Plan says there is no need for an intensive program consisting of
3 hours of therapy a day.
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 physician reviewer found
that the enrollee was admitted to the acute hospital after a fall, sustaining a left hip fracture. Functionally, he is
at a supervision assist level for bed mobility and transfers, and at a modified independence for ambulating.
The enrollee's comorbid conditions are stable and there are no acute or complex rehabilitation nursing needs.
Although the enrollee needs physical and occupational therapy, he does not need intensive therapies with a
multidisciplinary approach.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says a ventilator with settings that could be delivered by BiPAP is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 requested device. Our physician reviewer found that you have carbon dioxide retention while recovering from acute respiratory illness. The cause may be a combination of COPD, obesity-hypoventilation syndrome, and narcotic use. There are no pulmonary function tests to support the diagnosis of COPD. BiPAP during sleep may be of benefit for the patient. However, Medicare does not cover a home ventilator when used as BiPAP. Therefore, the requested device is not considered medically reasonable or necessary.
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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray of the knee (73562) provided on
September 24, 2021, at an outpatient hospital facility.
You asked the Plan to waive the copayment for an X-ray of the knee. You say that the claim was mistakenly
filed not as a specialist visit but as an outpatient visit. The Plan denied your request. The Plan says the correct
copayment was applied.
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 $100
copayment for diagnostic procedures and tests provided at an outpatient hospital.
You have been asked to pay a $74.44 copayment for an X-ray of the knee. An X-ray of the knee falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have
been asked to pay less than or equal to the full and 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 an X-ray of the knee (73562) provided on September 24, 2021, at an outpatient hospital facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The records do not show that the enrollee has a condition which would require more than 25 days of continued inpatient hospital care with daily doctor visits and specialized nursing care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there 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 he/she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology for prostate biopsy rendered on
November 11, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.
In this case, the MUE for CPT code G0416 is 1. The MAI value for this code is 2. You billed 12 units of this
code, exceeding the MUE. 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 the surgical pathology
for prostate biopsy rendered on November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series
of intraoral x-rays (D0210), and prophylaxis (D1110) provided on August 26, 2021 by an out-of-network
(OON) provider.
You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and
prophylaxis. You say that you would like to be reimbursed in the amount of $2,300.00 that you paid out of
pocket for dental work. The Plan denied your request. The Plan says this plan does not cover services from a
provider who is not in-network. The Plan also says that the treating provider was not contracted on this date of
service.
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
covered when they are received OON Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and prophylaxis (D1110)
provided on August 26, 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 radiology and laboratory services provided on September 17,
2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the radiology and laboratory services. You say that the services were medically
necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the services at issue were urgent or emergent.
Therefore, we decided that the Plan does not have to pay for radiology and laboratory services provided on September 17, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable infusion pump.
You asked the Plan to pre-approve an implantable infusion pump. You say that the requested implantable
infusion pump is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet
criteria for the requested implantable infusion pump.
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 an implantable infusion pump. Our
reviewer says that the enrollee does not meet criteria for the requested implantable infusion pump. Our
physician reviewer found the enrollee has multiple sclerosis. She has significant muscle spasms. There is no
documentation of the precise results of the Baclofen trial that was conducted. Medicare requires that a
documented trial be conducted. This is not present in the records. Therefore, the request is deemed not
medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an implantable infusion pump have not been met. Therefore, we decided that
the Plan does not have to pre-approve an implantable infusion pump.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee on August 16, 2021.
You asked the Plan to pay for the services. You say that the procedure was rendered in the appropriate level of service. The Plan denied your request. The Plan says this was billed with an inappropriate place of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 71045 is "Radiologic examination, chest; single view." We find that CPT code 71045 is not supported in the medical record. Specifically, the claim shows a place of service of 22 - outpatient, but the claims history shows that the enrollee was inpatient during the denied date of 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 radiology services provided to the enrollee on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard and 9 fillings provided from September
10, 2021, to September 30, 2021, by an out of network dentist.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied
your request. The Plan says dental services received out of network are not covered.
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, dental services received out of network
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for
the occlusal guard and 9 fillings provided from September 10, 2021, to September 30, 2021, by an out of
network dentist.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that if you do not get therapy services as soon
as possible, there is an increased risk that your overall level of function will decline. The Plan denied your
request. The Plan says your request for approval of admission to a skilled nursing facility (SNF) does not meet
the requirements for approval.
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 the SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. Our
reviewer found that you do not have daily skilled therapy needs that require the specialized skill, knowledge,
and judgment of a skilled professional therapist. Our physician reviewer also found that you do not require
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
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 SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pressure reducing mattress (E0277).
You asked the Plan to pre-approve a pressure reducing mattress. You say that this is medically necessary. The
Plan denied your request. The Plan says that you do not meet the criteria because you have one Stage II ulcer.
The Plan must follow Medicare rules. Medicare rules say that a pressure reducing mattress can be covered if
Medicare criteria are met.
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 a pressure reducing mattress. Our
reviewer says that the requested pressure reducing mattress is not considered medically reasonable and
necessary in this case. Provided records do not document current presence of multiple stage 2 pressure ulcers
located on the trunk or pelvis which have failed to improve over the past month during which time you have
been on a comprehensive ulcer treatment program or large or multiple stage 3 or 4 pressure ulcer(s) on the
trunk or pelvis or a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60
days. Our physician reviewer found that your condition does not meet Medicare criteria for a pressure reducing
mattress.
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 pressure reducing mattress have not been met. Therefore, we decided that the
Plan does not have to pre-approve a pressure reducing mattress (E0277).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an inpatient hospital stay and ambulance
services provided from August 21, 2021, to August 29, 2021.
You asked the Plan to waive the copayments for an inpatient hospital stay and ambulance services. You say
that you disagree with the charges because you were discharged too early from a previous hospital stay while
you were still having low oxygen due to the coronavirus. The Plan denied your request. The Plan says the
claims were processed correctly and you are being charged the correct amount.
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 $350
copayment for days 1-5 for inpatient hospital care. Your contract with the Plan also clearly says that you must
pay a $250 copayment for ambulance services.
You had an inpatient hospital stay from August 21, 2021, to August 26, 2021. Therefore, you are responsible to
pay a $350 copayment for days 1-5 (August 21, 2021, to August 25, 2021). The total amount you owe is: $350
(copayment) x 5 (inpatient days) = $1,750.
You received ambulance services on August 29, 2021. Therefore, you are responsible to pay the $250
copayment.
The total amount you owe is: $2,000.
You have been asked to pay the total copayment amount of $2,000 for an inpatient hospital stay and ambulance
services. An inpatient hospital stay falls within the inpatient hospital care benefit category. Ambulance services
fall within the ambulance services benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for
an inpatient hospital stay and ambulance services provided from August 21, 2021, to August 29, 2021.
Your quality of care concerns have been handled separately by the Plan. Medicare does not permit MAXIMUS
to make a decision on this type of complaint.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha.
You asked the Plan to pre-approve Repatha. The Plan denied your request. The Plan says Repatha to be
administered at home is not covered under the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pre-approve Repatha.
Benefits for Repatha may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.