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 medical records provided support the need for 
the requested IRF admission. 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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for respiratory failure, chronic obstructive pulmonary disease (COPD) and bradycardia. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. 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. There is not a reasonable expectation that the enrollee 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95909, 95938 and 95886 billed for date of 
service November 9, 2022. 
 
You asked the Plan to pay for procedure code(s) 95909, 95938 and 95886. You say that the services were billed 
correctly and should be paid. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95909, 95938 and 
95886. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 95909, 
95938 and 95886. Based on this information, we decided that Medicare rules for coverage of procedure code 
95909, 95938 and 95886 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 95909, 95938 and 95886 billed for date of service November 9, 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 services are medically necessary. The Plan 
denied your request. The Plan says while the enrollee may benefit from continued therapy, they can reasonably 
be expected to continue their recovery at a lower level of care with good success.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for an LTACH admission. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that they 
are not currently receiving, but that would be available at the LTACH facility. The elements of coverage rules 
are not satisfied. The requested service cannot be recommended. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for radiofrequency ablation for the enrollee.

You asked the Plan to provide coverage for radiofrequency ablation. You say that at the time of the appeal,
radiofrequency ablation was medically necessary. The Plan denied your request. The Plan says the Medicare
coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated
that Maximus did not apply the correct criteria.

The Plan noted that the medical records dated May 18, 2023, state prior to this visit the enrollee experienced
greater than 12 months of moderate to severe pain with difficulty getting in and/or out of a bed, chairs,
difficulty with activities of daily living and difficulty with stairs to the point of concern for safety issues. The
Plan stated these statements would not indicate the enrollee received at least 50% relief of his pain for at least a
year after the initial radiofrequency procedure.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare requires specific
documentation in the case file show the required coverage criteria for this treatment are met. Based on the
medical records provided, there is insufficient information to show the enrollee received at least 50% relief of
the present pain for at least a year after the initial radiofrequency procedure. The Medicare coverage criteria
were not met. Therefore, we decided that the Plan does not have to provide coverage for radiofrequency
ablation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg and foot to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the OON prosthetics. You say that you are the preferred provider for the 
enrollee's facility. The facility has had issues with another nearby provider and goes out of their way to work 
with you. You feel that for this reason, OON coverage should be approved.  The Plan denied your request. The 
Plan says there are in-network providers who can furnish the items required by the enrollee. As there is no 
deficiency, the denial for OON coverage is correct.  
 
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 
a prosthetic leg and foot to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a flex-walk foot (L5981) for the enrollee.

You asked the Plan to provide coverage for a flex-walk (L5981). You say that a flex-walk foot described by
code L5981 was medically necessary at the time of the appeal. The Plan denied your request. The Plan says
Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen
and stated that Maximus did not apply the correct criteria. The Plan noted that the enrollee's current foot is a
K3 foot. This is the same functional level as the requested foot. The enrollee's current foot is under warranty.
There is no documentation in the medical records of damage or irreparable damage to the current foot. The
requested K3 foot exceeds the enrollee's need as the current foot is under warranty and is the same functional
level.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not replace, repair, or
maintain prosthetic equipment that is under warranty. Based on the records provided, there is no reported
functional issued with the current foot. If there was a functional repair need, that would still be covered under
the warranty and not by Medicare. Therefore, we decided that the Plan does not have to provide coverage for a
flex-walk foot (L5981) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records show that you are able to perform self-care in the home, including doing laundry. You do not require a power scooter to perform self-are 
activities in the home. The criteria for coverage are not met and the power scooter is not reasonable or 
medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
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 the enrollee 
to receive the care needed to address their immediate concerns and to prevent readmission. The Plan denied 
your request. The Plan says the enrollee does 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented home health occupational therapy needs. The enrollee appears to be functioning at a 
level commiserate with a lower level of care. As such the requested, ongoing, home health occupational 
therapy services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cataract surgery provided on January 
13, 2022, and January 27, 2022. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that you are unhappy and very 
unsatisfied, so you should not have to pay the billed amount. 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 $250 
copayment per day for other outpatient procedure and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical 
center. 
 
You have been asked to pay a total of $500 for the cataract surgery ($250 copayment x 2 visits = $500). This 
item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 cataract 
surgery provided on January 13, 2022, and January 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrocardiogram (93000) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve an electrocardiogram. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the enrollee must use network providers to get medical care and services. 
 
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 
an electrocardiogram (93000) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional acupuncture treatments in 2023.

You asked the Plan to provide coverage for additional treatment. You say that at the time of the appeal,
additional treatment was medically necessary. The Plan denied your request. The Plan says the 6 covered visits
under the contract were exhausted. Maximus overturned the Plans denial for a lack of claim information in the
case file. The Plan requested a reopen and provided the additional documentation.

The Plan is correct in this case. The rules say that acupuncture services are not covered by Medicare. However,
the Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage
rules apply in this case. The Plan covers 6 visits under the contract and provided documentation to show 6
visits had been paid for by the Plan. Therefore, we decided that the Plan does not have to provide coverage for
additional acupuncture treatments in 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of Zoledronic Acid is required before alternatives can be considered. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drugs or 
any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling/planing (D4341x2) provided from June 16, 2023, 
to June 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing this denial. 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 dates of service September 4, 2020, and 
September 25, 2020. Therefore, we decided that the Plan does not have to pay for the scaling/planing 
(D4341x2) provided from June 16, 2023, to June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment and abutment supported
crown (D6057, D6058) for tooth #12.

You asked the Plan to pre-approve a custom fabricated abutment and abutment supported crown for tooth #12.
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 the requested item or service has already been exhausted. Maximus overturned the
Plan's denial. The Plan requested a reopening and indicated that they have provided coverage up to the benefit
maximum for these services. The Plan is correct in this case. Though the Plan offers a dental benefit in excess
of Medicare coverage, certain limitations apply. The record shows your benefit for supplemental
comprehensive dental services was exhausted on date of service March 21, 2023. The Plan has shown that with
the approval of the custom fabricated abutments and abutment supported crowns (D6057, D6058) for teeth #14,
19 and 30 that you have used your $5,000 benefit. Therefore, we decided that the Plan does not have to preapprove
a custom fabricated abutment and abutment supported crown (D6057, D6058) for tooth #12.