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 the services are medically necessary for you to 
receive therapy services to regain your mobility before returning home. The Plan denied your request. The Plan 
says you do not meet the criteria for admission to an IRF.  
 
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 you do 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an increase in home health aide (HHA) hours. 
 
You asked the Plan to pre-approve additional HHA hours. The Plan denied your request. The Plan says the 
patient is currently receiving the appropriate HHA hours. The Plan also says there is no documentation to 
support the medical necessity need for an increase in HHA services as requested.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 
 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 additional HHA hours. Our reviewer 
says that additional hours of home health aide assistance is not medically necessary. Our physician reviewer 
found the patient is noted to be medically stable and does not require skilled nursing care. The patient does 
require assistance with mobility and daily activities given their Alzheimers Disease and dementia and is 
currently receiving assistance from her daughter. Our reviewer also found that the calculated need for personal 
care assistance is noted to be 24.75 hours and there is no indication that the patient requires additional personal 
care assistance for mobility and performing daily activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional HHA hours have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an increase in home health aide (HHA) hours.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay $36 more for the frame. We decided that the Plan does not have to pay for 
the progressive lens, polycarbonate lens, and anti-reflective coatings.  
 
  You asked the Plan to pay for the progressive lens, polycarbonate lens, and anti-reflective coatings, and to pay 
more for the frame provided on September 11, 2023. You say that you have not gotten glasses in two to three 
years, and needed new ones. The Plan says that you chose lens enhancements that are not covered in full by the 
Plan. The Plan also says that you chose a frame that exceeded your frame allowance, and you are responsible 
for the $36.00 difference. 
 
We decided that the Plan has to pay $36 more for the frame.  
 
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 pays up to $200 for eyeglasses (frames and lenses) every two years. 
 
We looked at the file and the Plan's rules. The information provided shows the Plan paid a total of $131 for the 
eyewear, leaving you with a balance of $36 for the frames. The record does not show that the Plan paid the full 
$200 eyewear allowance or that it had been exhausted with this purchase. Based on this information, we 
decided that the Plan's rules for coverage of the frame have been met. Therefore, we decided that the Plan has 
to pay $36 more for the frame.  
 
We also decided that the Plan does not have to pay for the progressive lens, polycarbonate lens, and anti-
reflective coatings. 
 
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. 
 
We looked at the file and the Plan's rules. The progressive lens, polycarbonate lens, and anti-reflective coatings 
are considered lens upgrades which are not covered by the Plan. Based on this information, we decided that the 
Plan's rules for coverage of the progressive lens, polycarbonate lens, and anti-reflective coatings have not been 
met. Therefore, we decided that the Plan does not have to pay for the progressive lens, polycarbonate lens, and 
anti-reflective coatings. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OrthoFix Trinity Elite Allograft (20930). 
 
You asked the Plan to pre-approve OrthoFix Trinity Elite Allograft. 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 OrthoFix Trinity Elite Allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the services are experimental when used as bone graft. Iliac crest autograft is gold standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OrthoFix Trinity Elite Allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve OrthoFix Trinity Elite Allograft (20930).
Appeal type: Transportation
Decision: Unfavorable

We decided that Plan does not have to pay for air ambulance transport provided to the enrollee on October 4,
2022.

You asked the Plan to pay for this transport. The Plan denied your request. The Plan says the records provided
do not indicate why the enrollee could not be treated at the originating facility and the enrollee was not
transported to the next nearest facility that could provide treatment as is required by Medicare. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria.

The Plan is correct in this case. The Plan follows Medicare rules. The rules say that Medicare pays for air
ambulance services only if your medical condition is such that transportation by ground ambulance is not
appropriate, you cannot be treated at the originating facility, and you are transported to the nearest facility
geographically that can provide the required treatment. Based on the records provided, there is insufficient
information in the case file to explain the need for the transfer to another facility. The records also show the
enrollee was not transferred to the nearest facility that could provide continued treatment.

The enrollee was transferred from Billings, Montana to Seattle, Washington, which is the enrollee's home state.
It should also be noted the medical records state the Washington hospital was the only hospital that appears to
have been contacted for treatment, which is 820 miles away from the originating Montana facility. Medicare
rules for coverage of these services were not met. Therefore, we decided that the Plan does not have to pay for
air ambulance transport provided to the enrollee on October 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for these dental services.

You asked the Plan to provide coverage for these dental services. The Plan your request. The Plan says the
$3000 benefit was exhausted prior to these services. Maximus partially overturned the Plans denial. The Plan
requested a reopen and provided additional information to show the years previously paid dental benefits.

The Plan is correct in this case. Medicare generally does not cover dental services. However, the Plan offers a
dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the maximum $3000 benefit was
exhausted prior to the request for these services. Therefore, we decided that the Plan does not have to provide
coverage for crowns (resin-based) for tooth #'s 6, 7, 11, 24, 25, and 28 (D2710), and a crown,
(Porcelain fused) for tooth #'s 11 and 28 (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93229) provided on September 12, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93229 is "External mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of 
accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events 
transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and 
patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports 
as prescribed by a physician or other qualified health care professional".  
We asked our coder 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 services. Our reviewer says that the use of code 93229 is 
not supported by the records provided. Our reviewer found that the record does not contain a description of 
cardiovascular telemetry with real time data analysis with electrocardiogram (ECG) triggered and patient 
selected events transmitted to a remote surveillance center. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (93229) provided on September 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open R hip gluteus medius tendon repair (27299). 
 
You asked the Plan to pre-approve open R hip gluteus medius tendon repair. 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 open R hip gluteus medius tendon 
repair. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is experimental treatment for hip pain. More research 
is needed to show the safety and efficacy of the procedure. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of open R hip gluteus medius tendon repair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve open R hip gluteus medius tendon repair (27299).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on August 02, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this patient is in a facility, and you depend upon the 
facility staff for any verification or prior authorization. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a facility visit provided 
on August 02, 2023.
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines, the IRF services requested do not meet the 
requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that while the medical record supports a need 
for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. Our physician reviewer also found that 
there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99284) provided 
on June 26, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99284). You say that procedure code 
99284 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue 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 CPT code. 
 
 In this case, the CPT Code Manual definition of code 99284 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
We asked our coder 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 an emergency department visit (procedure 99284). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the enrollee was evaluated in the emergency department (ED) for foot/ankle pain and swelling. The records 
support an appropriate history and physical were obtained; However, there appears to be no concern that this 
was anything more than a localized issue and the medical decision making was not of moderate complexity. As 
such, the billing of CPT 99284 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99284) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99284) 
provided on June 26, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hydrocodone-acetaminophen. 
 
You asked the Plan to pre-approve the medication. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve hydrocodone-
acetaminophen.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic for tooth # 31 (D2740). 
 
You asked the Plan to pre-approve crown - porcelain/ceramic. You say that this is medically necessary. The 
Plan denied your request. The Plan says they approved crown - porcelain fused to high noble metal (D2750) 
saying that is sufficient treatment for tooth #31 instead of crown (D2740). 
 
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 crown - 
porcelain/ceramic when the services are medically necessary and reasonable.  
 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 crown - porcelain/ceramic. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the coverage appears to 
be less costly for the metal-ceramic crown under code 2750 than the ceramic crown under code D2740. The 
functionality of the crowns are equal, and either would serve the function of the needed service. D2740 does 
not meet the Plan criteria as there is a clear alternative at lesser cost. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of crown - porcelain/ceramic have not been met. Therefore, we decided that the 
Plan does not have to pre-approve crown - porcelain/ceramic for tooth # 31 (D2740).
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 patient meets IRF criteria and is reasonably 
expected to participate in and benefit from 15 hours of therapy per week. You also say that the patient requires 
daily physician oversight to actively manage medical conditions and comorbidities, and to optimize recovery 
and avoid re-hospitalization during intensive rehabilitation. The Plan denied your request. The Plan says based 
on Medicare guidelines, the IRF services requested do not meet the requirements for approval.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that while the medical record supports a need 
for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. Our physician reviewer also found that 
there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.