Persius/hicric huggingface dataset:
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 at the LTACH the enrollee's needs will 
be met daily and will continue to manage the other medical issues confidently. The Plan denied your request. 
The Plan says the enrollee is receiving appropriate in-patient 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 appears to be somewhat unstable at this time and requires short-term 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer. The enrollee does not require services at the LTACH that are not available and covered 
at the current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet stable and it 
would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 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: 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 would benefit from inpatient rehabilitation 
services due to your medical complexity. The Plan denied your request. The Plan says IRF is not medically 
necessary, and your needs can be met at a lower level of care. 
 
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 there are no complex nursing or rehabilitation needs. While you have 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more 
beneficial than Intensity modulated radiation therapy/Image-guided radiation therapy (IMRT/IGRT). The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to enrollees.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Radiation Therapy (PBRT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MLH1 (mutL homolog 1, colon cancer, nonpolyposis 
type 2) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence 
analysis (81292). 
 
You asked the Plan to pre-approve genetic testing. You say that you underwent a total hysterectomy on 
December 15, 2021, after which subsequent pathology indicated the loss of PMS2 on IHC for MMR. You were 
seen in genetic oncology as a result since this abnormality can indicate Lynch Syndrome. You also say that 
should the test confirm Lynch Syndrome it would impact therapeutic decision-making by guiding the 
frequency of colon cancer screenings. The Plan denied your request. The Plan says the breast cancer two of 
your family members have had is not the same type of cancer or a cancer related to the requested tests. The 
documentation available indicates you are already being monitored routinely for colon polyps, a precursor to 
colon cancer. The requested test is a non-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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found MSI proteins are MLH1, MSH2, MSH6 and PMS2 as plan already approved the latter 3, and 
PSM2 deficient, you meet criteria for MSI (lynch syndrome) thus as lynch syndrome and MSI confirmed, there 
is no need for MLH1. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary non-
polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis (81292).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Reader. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 Reader. You say that your physician prescribed the 
sensor so you could keep track of your glucose levels. The Plan denied your request. The Plan says you do not 
use insulin with at least three daily injections. 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the Freestyle 
Libre 2 Reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre 2 Reader.
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 need physical therapy to be able to get your 
strength back. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and 
your needs can be provided safely 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. Our 
physician reviewer found that your functional status does not require intensive rehabilitation or frequent 
physician oversight. 
 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 IRF admission and services.
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 medical complexity. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. Continued stay 
at acute hospital until the enrollee is stable enough for discharge to a lower level of care has not been denied. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan on 
September 29, 2022. 
 
You asked the Plan to waive the copayment for CT scan. 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 $225 
copayment for all other diagnostic and nuclear medicine radiological services. Covered services include but are 
not limited to other outpatient diagnostic tests. The provider billed in the amount of $1,466 and the allowed 
amount is $193.98. This is less than the copayment amount. Therefore, results in the total cost sharing amount 
of $193.98. 
 
 
 You have been asked to pay a $193.98 copayment, which is less than the copayment for CT scan. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 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 computed tomography (CT) scan on September 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and 
endodontic therapy, anterior tooth (D3310) provided on October 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dentist did not want to work on your root 
canal in fear of you losing the tooth. You also say that you hope the Plan will help pay for the dental work as 
you didn't want to lose the teeth you have. The Plan denied your request. The Plan says your benefit for the 
limited oral evaluation - problem focused (D0140) has already been exhausted and the endodontic therapy, 
anterior tooth (D3310) is not covered under the benefit package. 
 
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 limited oral evaluation - problem focused (D0140) was exhausted on date of service 
October 24, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - 
problem focused (D0140), and endodontic therapy, anterior tooth (D3310) provided on October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown on tooth #13 (D2740) provided on 
October 19, 2022. 
 
You asked the Plan to pay for a crown. You say that you are not satisfied because the Plan only paid for your 
cleaning and x-rays. The Plan denied your request. The Plan says that if a method of treatment is more costly 
than is customarily provided, benefits will be paid on the least costly method of treatment, and you will be responsible for the remaining balance. The Plan also says you have been charged the correct cost sharing 
amount. 
 
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 Plan covers a crown 
(D2740) when the services are medically necessary and reasonable. The Plan will pay for the least costly 
treatment that will produce a satisfactory result. The Plan rules say you are responsible for 50% coinsurance of 
the allowed amount for the least costly treatment. The Plan rules also say you are responsible for the difference 
between the least costly treatment and the treatment you received. 
 
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 a crown. Our reviewer says that the criteria 
for coverage has not been met for a crown. Our physician reviewer found that a base metal crown would be as 
functional as a zirconia crown in any situation where there was no allergy to the material.  A crown with base 
metal (D2751) would have produced a satisfactory result. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
you have been charged the correct cost sharing amount. You have been asked to pay 50% coinsurance of the 
allowed amount for the least costly treatment ($857 base metal crown allowed amount x 50% coinsurance = 
$428.50). You have also been asked to pay the difference between the least costly treatment and the treatment 
you received ($933 porcelain/ceramic crown allowed amount - $857 base metal crown allowed amount = $76). 
Your total responsibility is $504.50 ($428.50 + $76 = $504.50). Therefore, we decided that the Plan does not 
have to pay for a porcelain/ceramic crown on tooth #13 (D2740) provided on October 19, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on March 2, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and provided additional information. The Plan demonstrated that this claim denied
because it was billed inappropriately. The coding submitted is not supported as there is a more appropriate code
used for this service. The Centers for Medicare and Medicaid Services National Correct Coding Initiative
Policy Manual Chapter 10: Pathology / Laboratory explains that if all tests of a defined panel are performed,
the provider or supplier shall bill the panel code. The panel codes shall be used when the tests are ordered as
that panel.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, this claim
denied due to the omission of the required panel code. Medicare rules for coverage of these services have not
been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on
March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI) benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you are appealing the denial of the SSBCI 
for utility flex card benefit. The Plan denied your request. The Plan says there is no documentation that the 
enrollee meets criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one 
of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have 
to pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI) benefits.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for lab services provided to the enrollee from July 14, 2021 to July 20, 2021.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that claims that have an Outpatient Code Editor (OCE) Edit Error with a disposition of "Return to Provider (RTP)" are to be returned to the provider for corrections. They may resubmit the claim once the OCE edit errors with the RTP disposition has been corrected. Once the corrected claim was received, then the plan would review all of the other line items on the claim in addition to the ones that previously denied with the RTP dispositioned OCE edit errors. As there are OCE edit errors on this claim with a disposition of RTP, the Plan was required to return the claim to the provider to address those issues.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the claim was submitted with errors that require the Plan to return the submission back to the provider for correction.
Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee from July 14, 2021 to July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI) benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that the enrollee is on disability and this 
benefit will help with numerous chronic conditions. The Plan denied your request. The Plan says there is no 
documentation that the enrollee meets criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one 
of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have 
to pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI) benefits.
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 the medical records provided support the need for 
the requested 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 all the requirements for admission. 
 
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 enrollee is medically stable and does not need physical medicine and a  
rehabilitation physician's supervision 3 times a week in an IRF. There are no acute rehabilitation nursing needs 
identified or documented. The enrollee does not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. It is unlikely that the 
enrollee will tolerate and make a significant functional recovery in a reasonable period of time in an IRF. While 
the enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehabilitation needs 
can be provided in a lower intensity and alternate setting such as in an 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.