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

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve dental implants. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental implants.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visit and inpatient 
hospital stay provided from December 6, 2021, to December 12, 2021. 
 
You asked the Plan to waive the copayments for the specialist office visit and inpatient hospital stay. You say 
that the enrollee was charged more than the out-of-pocket maximum. 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 $40 copayment for each specialist office visit. The enrollees contract with the Plan also clearly 
says that enrollees must pay a $400 copayment per day for days 1-4 of each inpatient hospital stay. 
 
The records show the enrollees out-of-pocket maximum was processed correctly. The enrollee has been asked 
to pay a $40 copayment for the specialist office visit provided on December 6, 2021. This item/service falls 
within the physician/practitioner services benefit category.  
 
The enrollee has also been asked to pay a $400 copayment per day for days 1-4 of the inpatient hospital stay 
provided from December 7, 2021, to December 12, 2021. This item/service falls within the inpatient hospital 
care benefit category. The enrollee has not been asked to pay after day four, or for the day of discharge. The 
enrollee has been asked to pay a total of $1,600 for the inpatient hospital stay ($400 copayment per day x 4 
days = $1,600). 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. 
Therefore, we decided that the Plan does not have to waive the copayments for the specialist office visit and 
inpatient hospital stay provided from December 6, 2021, to December 12, 2021.
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 enrollee requires physical therapy to work on 
increasing strength, endurance, functional mobility, balance, and stairs. The Plan denied your request. The Plan 
says an IRF admission is not medically necessary, and the enrollee's needs can be met at an alternate 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional skilled nursing facility services. 
 
You asked the Plan to pre-approve additional skilled nursing facility services. You say that the enrollee 
continues to require skilled nursing care due to multiple medical comorbidities. The Plan denied your request. 
The Plan says the enrollee will have/have used more skilled nursing facility days than are covered under your 
Plan during the current benefit period. 
 
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 September 14, 2022, 
through May 14, 2023. 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 pre-approve additional skilled nursing facility services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 fractions of 3D conformal Image Guided Radiation 
Therapy (IGRT). 
 
You asked the Plan to pre-approve 10 fractions of IGRT. You say that medical documentation from the 
enrollee's chart is attached to support the medical necessity for this case. The Plan denied your request. The 
Plan says the records show that the enrollee has cancer. The reason this request cannot be approved is because 
there is no current research showing that her type of cancer responds better to the requested type of treatment 
than the type of treatment the Plan can approve. 
 
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 10 fractions of IGRT. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found for most cases of palliative treatment of metastases, even when a CT scan is used for 
treatment planning purposes, and when a 3D dose matrix generated, for billing purposes, it is the accepted 
standard to bill 2D radiation and not 3D radiation. Generally, 3D radiation is necessary when the 2D radiation 
plan results in unacceptable normal tissue dose exposure and toxicity risks (uncommon with palliative 
treatment). It usually implies the need to spare normal tissues in a manner that cannot be achieved with 2D 
radiation. For bone metastases with soft tissue involvement, billing for 3D radiation is an accepted standard per 
Evicore guidelines, due to more complex treatment planning to not only cover the bone, but also the soft tissue 
component and the added complexity of sparing normal tissue when targeting bone plus soft tissues. For this 
enrollee, there is no indication of an extensive soft tissue component. IGRT is a means to improve set-up 
accuracy. IGRT uses daily image guidance to help localize the target so as to minimize normal tissue dosing. 
Specifically, IGRT allows accuracy of treatment delivery, so when generating a planning target margin, the 
margins can be reduced, and thus allow reduction in the volume of normal tissues exposed to radiation. For 
bone metastases it would generally not be standard to bill IGRT without a plausible rationale to do so. The 
decision is therefore unfavorable for 3D conformal radiation and IGRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 fractions of IGRT have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 fractions of 3D conformal Image Guided Radiation Therapy (IGRT).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on July 7, 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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and demonstrated this claim denied because the provider billed this service with an inappropriate modifier. According to our review, the provider needed to bill the anatomic specific modifiers LT (Left side), RT (Right side), and 50 (Bilateral procedure) to designate the area or part of the body on which the procedure is performed. The Plan provided the claim image that shows the provider billed this service without the appropriate modifier.
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, this claim could not be paid as billed due to the omission of a required modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that 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 November 23, 2020. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye examination and the refraction provided on 
July 19, 2022. 
 
You asked the Plan to pay for the medical eye examination and the refraction. You say that pre-certification is 
not required for an eye exam for codes 92014 and 92015. The Plan denied your request. The Plan says services 
are not covered benefits. 
 
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 when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the medical eye examination and the refraction 
have not been met. Therefore, we decided that the Plan does not have to pay for the medical eye examination 
and the refraction provided on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination and eyeglasses provided on February 2, 
2023, by an out-of-network provider.  
You asked the Plan to pay for the vision services. You say that you thought the services would be covered with 
this provider. The Plan denied your request. The Plan says vision services with out-of-network providers are 
not covered. 
 
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 when you utilize an in-network provider. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for 
an eye examination and eyeglasses provided on February 2, 2023, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the medical supplies and meals provided on January 7, 
2023. 
 
You asked the Plan to pay more for medical supplies and meals. You say that you want to be reimbursed 
$84.42. You say you do not agree with the approved amount. The Plan denied your request. The Plan says the 
benefit has been exhausted. 
 
Medicare generally does not cover OTC items. However, the Plan offers an OTC item benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you only had a quarterly balance of $28.35 remaining on your savings care. The record shows you were 
reimbursed $28.35 which exhausted your quarterly benefit. Therefore, we decided that the Plan does not have 
to pay more for the medical supplies and meals provided on January 7, 2023.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for cerebral perfusion analysis billed with code 0042T provided to the enrollee on September 8, 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 for insufficient information in the case file and improper jurisdiction for the guidelines used. The Plan requested a reopen and stated that this service was billed with an inappropriate diagnosis code. The Plan noted the diagnosis of giddiness and dizziness is not as an acceptable diagnosis code for the service provided.
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 diagnosis code. This provider is within the appropriate jurisdiction and the diagnosis code listed in not one of those listed as a covered diagnosis for this testing.
Therefore, we decided that the Plan does not have to pay for cerebral perfusion analysis billed with code 0042T provided to the enrollee on September 8, 2022.
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 feels that they still are in need of the 
acute patient rehab. The Plan denied your request. The Plan says an intensive rehabilitation program is not 
medically necessary.  
 
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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 1, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says an incorrect place 
of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on August 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic drug injection (D9612) and evaluation for 
sedation or general anesthesia (D9219). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be rendered as per the 
advice of your provider. You say you are dissatisfied that you need to pay a huge amount for services that 
should be covered by insurance. The Plan denied your request. The Plan says the services are not covered 
under your benefit plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic drug injection (D9612) and evaluation for sedation or general anesthesia (D9219).
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 like reconsideration because the services 
are medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and your needs can be met at an alternate 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two (2) outpatient office visits with an orthopedic 
surgeon to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve office visits. You say that you are in a lot of pain. You called the requested 
provider for an appointment, and they will not see you without a referral. Your primary physician is out of the 
office, and you do not want to be seen by the covering physician. The Plan denied your request. The Plan says 
your primary care physician would like to schedule an appointment to be seen in the office. The medical 
records received from your specialist, did not include the necessary procedural codes or diagnosis for your 
request. You do not meet criteria to see an OON provider. 
 
 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 records show the Plan 
contacted your primary care physician (PCP) and they would like to see you at the office. The records also 
show the requested provider will not see you without a PCP referral which has to have your diagnosis and 
procedural codes needed for the visit. 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 two (2) outpatient office visits 
with an orthopedic surgeon to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from September 19, 2019, to October 18, 
2019. 
 You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility needs.  
 
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 pay for 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 that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from September 19, 2019, to October 18, 2019.