Persius/hicric huggingface dataset:
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 you were independent and active before coming to 
the hospital and want to return to being independent. The Plan denied your request. The Plan says you do not 
meet the Medicare criteria for admission to an Inpatient Rehabilitation Facility. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrodes (A4595) provided to the enrollee on September 15, 2022.
You asked the Plan to pay for the electrodes. You say that that the claim should be paid. The Plan denied your request. The Plan says that the provider did not submit any evidence that they have been contacting the member before shipping additional supplies. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that for all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary. We looked at the file and Medicare rules. The file does not include any documentation that there was contact between the supplier and beneficiary prior to the electrodes begin dispensed. Based on this information, we decided that Medicare rules for coverage of the electrodes have not been met. Therefore, we decided that the Plan does not have to pay for the electrodes (A4595) provided to the enrollee on September 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
July 26, 2022, to July 29, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not have to 
pay due to the poor quality of care. 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 $375 
copayment per day, for days 1 to 5 and a $0 copayment per day, for days 6 to 90 for inpatient hospital care.  
 
You have been asked to pay a $375 copayment per day, for days 1 to 3 of the inpatient hospital stay. You have 
been asked to pay a total of $1,125 ($375 copayment x 3 days = $1,125). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the inpatient hospital stay provided from July 26, 2022, to July 29, 
2022.  
 
Your complaint about the poor quality of care is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mental health visit provided on 
February 15, 2023. 
 
You asked the Plan to waive the copayment for the mental health visit. You say that you did not schedule the 
appointment. 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 $35 
copayment for outpatient mental health care. 
 
You have been asked to pay a $35 copayment for the mental health visit. This item/service falls within the 
outpatient mental health care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the mental 
health visit provided on February 15, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avastin. 
 
You asked the Plan to pre-approve Avastin. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Avastin. Our reviewer says that Avastin 
is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drugs Mvasi or Zirabev. Also, there is no indication that the Plan's required drugs would likely be 
mess effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Avastin have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avastin.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided from March 3, 2023, to 
March 12, 2023. 
 
You asked the Plan to pay for an eye refraction (92015). You say that you were not aware the refraction would 
not be covered if it was billed with a medical examination. The Plan denied your request. The Plan says  the 
provider performed these services for the member as a result of a medical diagnosis, not as part of a routine 
examination. The Plan also says that as a result, the service is excluded from coverage. 
 
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 they are part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that eye refractions are only covered when 
performed during a routine eye examination. The record shows this was a medical examination. Based on this 
information, we decided that the Plan's rules for coverage of an eye refraction (92015) have not been met. 
Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided from March 3, 
2023, to March 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adjustable height detachable armrest (E0973) and an 
armrest bracket (K0108). 
 
You asked the Plan to pre-approve an adjustable detachable armrest and an armrest bracket. The Plan denied 
your request. The Plan says that these items are unbundled and are unable to be requested separately. 
 
The Plan must follow Medicare rules. Medicare rules say that a power tilt and recline seating system includes 
detachable or flip-up fixed height or adjustable height armrests and any hardware that is needed to attach the 
seating system to the wheelchair base. 
 
We looked at the file and Medicare rules. An adjustable height detachable armrest and armrest bracket are 
included in the approved power tilt/recline system and cannot be requested separately. Therefore, we decided 
that the Plan does not have to pre-approve an adjustable height detachable armrest (E0973) and an armrest 
bracket (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for electrodes (A4595) provided on September 18, 2022.
You asked the Plan to pay for these supplies. 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 noted that the provider is renting the TENS Unit to the enrollee. Per Medicare guidelines, the provider should not bill separately for supplies. It is also noted that the provider has billed more than the Medicare allowed amount for these supplies.
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 as these supplies were billed separately in error for a rented item and were billed in excess of the number of supplies allowed by Medicare. The rules for coverage of these supplies have not been met. Therefore, we decided that the Plan does not have to pay for electrodes (A4595) provided to the enrollee on September 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter/crutch substitute (E0118).

You asked the Plan to pre-approve a knee scooter/crutch substitute. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that knee scooters and other crutch substitutes are not covered for any indication. Therefore, we decided that the Plan does not have to pre-approve a knee scooter/crutch substitute (E0118).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion (27280). 
 
You asked the Plan to pre-approve SI joint fusion. You say that this is medically necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of an open SI joint fusion in the absence of SI 
joint instability, fracture, or tumor/lesion have not been demonstrated in the peer-reviewed literature. SI joint 
fusion for degenerative back pain is 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 SI joint fusion. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no SI joint instability, fracture, or lesion. SI joint fusion for degenerative back pain is 
experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint fusion (27280).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a maxillary complete denture (D5110) and mandibular complete 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you have not used your dental benefits. 
The Plan denied your request. The Plan says that your benefit for the requested item or service has been 
exhausted. 
 
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. Requests for an explanation of benefits to verify your dental benefit of $1,000 
has been exhausted has not been forwarded. Additionally, there has not been to claim forwarded to show these 
services have already been received in order to dismiss the appeal. Therefore, we decided that the Plan has to 
pre-approve a maxillary complete denture (D5110) and mandibular complete denture (D5120).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional extractions and a bone replacement graft (D4341, 
D7210, D7953) provided on November 30, 2022, to December 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for extractions has already been 
exhausted. Coverage for the bone replacement graft denied correctly as it does not fall within your dental 
benefits. 
 
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, certain limitations apply. This benefit 
does not include bone replacement grafts. The record shows your benefit for the requested item or service was 
exhausted on date of service November 30, 2022. Therefore, we decided that the Plan does not have to pay for 
additional extractions or the bone replacement graft (D4341, D7210, D7953) provided on November 30, 2022, 
to December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the tertiary level outpatient office visits to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visits. You say that you contracted Omicron Covid-19 in January 2022. Since then, you have been on oxygen 24 hours a day. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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. The Plan has provided to you the recognized in-network tertiary care provider for these services.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 the tertiary level outpatient office visits to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the gym membership (S9970) 
purchased on January 1, 2021.  
 
You asked the Plan to issue additional reimbursement for this service. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have 
exhausted the allowable benefit for this service. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because you have exhausted the allowable 
benefit for this service. Specifically, the Plans contract states that the plan reimburses you up to $250 per 
calendar year towards your cost for membership in a qualified health club or fitness facility. The record shows 
that the Plan issued reimbursement to you on February 11, 2022 in the amount of $250 for the gym 
membership purchased for the 2021 calendar year. Therefore, you have exhausted the allowable benefit for this 
service. Therefore, we decided that the Plan does not have to issue additional reimbursement for the gym 
membership (S9970) purchased on January 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for code K0553 billed for August 18, 2022.
You asked the Plan to pay this claim. You say that these services should be paid by the Plan. 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 submitted the claim which shows the number of units submitted was incorrect.
The Plan is correct in this case. 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 claim shows an error in the number of units submitted. Code K0553 has an MUE value of 1, you billed 1 unit. Medicare rules for payment of this claim have not been met. Therefore, we decided that the Plan does not have to pay for to pay for procedure code K0553 billed for date of service August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osteogenesis stimulator, low intensity ultrasound, non-invasive (E0760).

You asked the Plan to pre-approve an osteogenesis stimulator. You say that the device is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria of the requested device.

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 osteogenesis stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has slight improvement in right lower extremity swelling and pain but continues to have recurrent pain and swelling. The documentation does not reveal a congenital pseudarthrosis or nonunion of a long bone fracture. The documentation does not reveal that there has been a minimum of 9 months since the enrollee's fusion.

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 osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an osteogenesis stimulator, low intensity ultrasound, non-invasive (E0760).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kidney transplant listing.
You asked the Plan to pre-approve this request . You say that this transplant is medically necessary. The Plan
denied your request. The Plan says there is insufficient information submitted by your physicians to show you
are an appropriate candidate. Maximus overturned the Plans denial. The Plan requested a reopen and note that
the information sent in with the appeal was insufficient. There was no dental clearance or colonoscopy results
provided. Your providers were notified that additional testing was required to be cleared for transplant listing.
No updated information was received from your physicians. Medicare does not have any National or Local
Coverage Decisions regarding kidney transplant specifically. The next best nationally recognized decision tool
would then be InterQual 2022, Apr. 2022 Release, CP:Procedures, Transplantation, Renal, which was used in
this case. InterQual requires that there is "No active infection or infection treated". A dental evaluation would
be needed to exclude any active oral infection that would preclude transplant. Medicare does have a National
Coverage Decision supporting the need for dental evaluation prior to kidney transplant as well - National
Coverage Determination (NCD) Dental Examination Prior to Kidney Transplantation 260.6. This further
supports that a dental clearance is appropriate prior to kidney transplant listing.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules state that providers and
physicians must submit documentation to show you are an appropriate candidate for the service requested.
There are insufficient records provided to show you have the general clearance such as dental and diagnostic
tests required prior to a transplant listing. As this medical clearance has not been clearly established, Medicare
rules for coverage are not met. Therefore, we decided that the Plan does not have to pre-approve kidney
transplant listing.