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

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on June 12, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you were not feeling well. You say that your 
son felt it was necessary to call an ambulance. You also say that you feel you should not have to pay for this 
service. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. The Plan 
also says since there was no transport provided, there is no payable 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 June 12, 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 the ambulance response and treatment, no 
transport, (A0998) provided on June 12, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve positron emission tomography (PET) testing. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the 
testing is not appropriate for other dementia workups. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Plans summary indicates medical records, including magnetic 
resonance imaging and abnormal clinical exams. Maximus requested the medical records that were used in 
their decision to deny services; however, none were submitted. The Plan has not made reasonable and diligent 
efforts to gather and forward to us information regarding their decision to deny your request.  Therefore, we 
decided that the Plan has to pre-approve positron emission tomography (PET) testing.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trigger point injection (20552) provided on April 13, 
2022. 
 
You asked the Plan to pay for the injection. You say that the injection was medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary for the enrollee's diagnosis. The Plan 
also says that the records do not include the necessary documentation.  
The Plan follows Medicare rules. Medicare rules say that the diagnosis of trigger points requires a detailed 
history and thorough physical examination. 
 
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 the injection. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the provided records do not contain the 
necessary documentation, including a detailed history and thorough physical examination, reason for selecting 
the trigger point injection as a therapeutic option. Therefore, the reviewer found that the criteria for coverage of 
the trigger point injection have not been met. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pay for the trigger point injection (20552) provided on April 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to get to your medical appointments. The Plan denied your request. The Plan says you have utilized the 
maximum number of transportation trips allowed per year. 
 
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 a maximum of 50 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 trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92002) provided on April 29, 2022. 
 
You asked the Plan to pay for the eye exam. You say that the first eye exam you received was incorrect, and 
you would like to appeal this service. The Plan denied your request. The Plan says you have exceeded the 
limits set in the subscriber agreement. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once per year. 
 
We looked at the file and the Plan's rules. The record shows that you received an eye exam on April 5, 2022, 
which was covered by the Plan, and your routine eye exam benefit has been exhausted. Based on this 
information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we 
decided that the Plan does not have to pay for the eye exam (92002) provided on April 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) and electrocardiogram 
(ECG) (93000) provided on May 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit and ECG. You say that you are the enrollee's primary 
care provider, and you are not in-network with the Plan. The Plan denied your request. The Plan says these 
services were rendered by a non-participating provider, and there is no referring provider involved. The Plan 
also says that prior authorization was not obtained by the provider or facility. 
 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. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99214) and 
electrocardiogram (ECG) (93000) provided on May 17, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services represented by code 81455 and billed for 
date of service January 11, 2022. 
 
You asked the Plan to pay for code 81455. You say that the targeted genomic sequence analysis panel was 
medically necessary and used to help determine treatment options. The Plan denied your request. The Plan says 
the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. 
 
The Plan must follow Medicare rules. Medicare rules say that the date of service of the test must be the date the 
specimen was collected, unless one of the three exceptions applies.  
 
We looked at the file and Medicare rules. The records show that the specimen was collected on December 23, 
2021, rather than the billed date of service of January 11, 2022. There is no documented evidence that one the 
three exceptions for billing outside of the date the specimen was collected applies in this situation. Based on 
this information, we decided that Medicare rules for coverage of code 81455 have not been met. Therefore, we 
decided that the Plan does not have to pay for laboratory services represented by code 81455 and billed for date 
of service January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the procedure is medically necessary 
and supported by science. The Plan denied your request. The Plan says it is considered experimental. 
 
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 requested services. Our physician 
reviewer found that the Intracept procedure is experimental for low back pain. More research is needed to show 
its safety and efficacy. Therefore, the request is 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visit and diagnostic
laryngoscopy provided on January 20, 2022, charged by the provider.
You asked the Plan to pay for these services in full. You say that you do not understand the amount covered by
the Plan since you have seen this doctor before, and it was covered in full. The Plan denied your request. The
Plan says that these services must be addressed under your Medicaid benefit by your provider.
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The
Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan
included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered
dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort.
Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care,
personal care, and home- and community-based services). These services qualified under the Medicaid
coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are
covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid
coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits.
Therefore, we decided that the Plan does not have to waive the cost share for the specialist office visit and
diagnostic laryngoscopy provided on January 20, 2022, charged by the provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stress test to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve stress test. You say that you only do stress tests at certain facilities. The 
Plan denied your request. The Plan says there is an in-network facility available, no network gap or continuity 
of care circumstances. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
stress test to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that without care the enrollee's condition will worsen. 
The enrollee cannot return home due to weakness and needs the skilled care. The Plan denied your request. The 
Plan says based on Medicare guidelines the skilled nursing facility services you are requesting do 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our 
reviewer also found that the enrollee does not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to provide continued SNF care. 
 
You asked the Plan to provide continued SNF care.. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee has exhausted their benefit and the SNF stay will not 
be covered after November 4, 2022. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from July 26, 2022, through 
November 4, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to provide continued SNF care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 9.75 day hours of personal care attendant 
services. 
 
You asked the Plan to pre-approve additional hours of personal care attendant services. The Plan denied your 
request. The Plan says coverage of solely personal care services, which are only custodial is not covered by 
Medicare for a beneficiary residing at home. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of additional hours of personal care attendant services have not been met. Specifically, we find that 
the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not 
have to pre-approve an additional 9.75 day hours of personal care attendant services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for an inpatient hospital stay provided by an out-of-network provder on 
May 21, 2022, to May 22, 2022. 
 
You asked the Plan to pay for an inpatient hospital stay. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that these services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan has failed to provide a 2022 Evidence of Coverage. 
Therefore, we decided that the Plan has to pay for an inpatient hospital stay provided by an out-of-network 
provider on May 21, 2022, to May 22, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the durable medical equipment (DME) 
provided from March 12, 2022, to April 16, 2022. 
 
You asked the Plan to waive the DME. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for durable medical equipment.  
 
Review of the file shows that the enrollee was provided DME. The enrollee has been asked to pay a 20% 
coinsurance for the DME. These items fall within the durable medical equipment benefit category. This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Additionally, sales tax is not a 
covered benefit by Medicare or the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the durable medical equipment (DME) provided from March 12, 2022, to April 16, 2022.
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. The Plan denied your request. The Plan says 
according to the information reviewed on appeal, the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 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. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet the requirements. 
 
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 was admitted for non-surgical management of a T 12 compression 
fracture after a fall. Medical problems are stable.  
 There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.