Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extra spinal chiropractic manipulative treatment. 
 
You asked the Plan to pre-approve extra spinal chiropractic manipulative treatment. You say that the 
chiropractor is grafting your knees and increasing the range of motion and greatly reducing the pain when you 
walk. You say that this will allow you to put off having to get a full knee replacement. The Plan denied your 
request. The Plan says the only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve extra spinal chiropractic manipulative treatment.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services received on Jun 8, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that the services were a medical emergency and 
should be paid. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services received on Jun 8, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport services received on 
May 3, 2023. 
 
You asked the Plan to pay for ambulance treatment without transport services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says without transport there are no payable 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 3, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport services 
received on May 3, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transport services provided on 
July 5, 2023. 
 
You asked the Plan to pay for the non-emergent ambulance transport services. You say that the transport 
services were medically necessary. The Plan denied your request. The Plan says the transport was to a non-
covered destination. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services from a doctors office to the 
enrollees home. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance 
transport services provided on July 5, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Opdualag. 
 You asked the Plan to pre-approve Opdualag. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of Keytruda or Opdivo alone, or Opdivo plus 
Yervoy before it will approve Opdualag. 
 
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 Opdualag. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Opdualag. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Keytruda or Opdivo alone, or Opdivo plus 
Yervoy. The record does not show that these drugs would likely be less effective and/or 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 Opdualag have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Opdualag.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 07, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. 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 an office visit provided 
on June 07, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on June 3, 2023 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the ED 
services provided on June 3, 2023
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 28, 2022, 
to January 10, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that I50.23 
is supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says I50.23 is not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
In this case, you billed the inpatient services provided with secondary diagnosis code I50.23, defined as acute 
on chronic systolic (congestive) heart failure. We asked our physician reviewer to carefully review the case file 
and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
inpatient hospital services at the DRG originally billed. Our reviewer says that secondary diagnosis I50.23 is 
not supported. Our physician reviewer found the enrollee was hospitalized with chest pain. They were found to 
have in-stent stenosis, for which a 2-vessel coronary artery bypass graft (CABG) surgery was performed. While 
the enrollee had chronic heart disease and the expected postoperative changes, there is no evidence that the 
enrollee had acute heart failure.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 28, 2022, to January 10, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PET scan with Fluorodeoxyglucose F18 provided on 
June 16, 2023, by an OON provider.  
 
You asked the Plan to pay for the PET scan with Fluorodeoxyglucose F18. You say that you are appealing the 
claim payment denial. The Plan denied your request. The Plan says the services were provided out-of-network 
and were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the PET scan with Fluorodeoxyglucose F18 
provided on June 16, 2023, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from May 31, 2023, to June 29, 
2023. 
 
You asked the Plan to pay for home health care. You say that you are appealing this denial. The Plan denied 
your request. The Plan says this admit date on this claim does not match the Notice of Admission (NOA) date. 
 
The Plan must follow Medicare rules. Medicare rules say that for home health care claims the admission date 
should match the From date on the first period of care in an admission.  
 
We looked at the file and Medicare rules. On this claim, the admit date does not match the start of care date. 
Based on this information, we decided that Medicare rules for coverage of home health care have not been met. 
Therefore, we decided that the Plan does not have to pay for home health care provided from May 31, 2023, to 
June 29, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from SNF services. The 
Plan denied your request. The Plan says the SNF services are not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in an SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that the radiofrequency ablation is 
vital to your quality of life and your ability to live pain free without taking pain pills constantly. The Plan 
denied your request. The Plan says the radiofrequency ablation is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that SIJ Denervation (also called Radiofrequency 
Ablation or RFA) is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiofrequency ablation have been met. Therefore, we decided that the Plan does not have to 
pre-approve the radiofrequency ablation of the sacroiliac joint.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you can only walk two steps and your pain level is 
still uncontrolled, you cannot care independently for yourself and there is no one home to help with the home 
care if youre discharged. The Plan denied your request. The Plan says your request does not meet Medicare 
guidelines because you no longer require skilled services on a daily inpatient basis and the continuation of SNF 
is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard  soft appliance, full arch (D9945). 
 
You asked the Plan to pre-approve the occlusal guard. You say that you need the mouth guard as you crunch 
your teeth at night. You also say that the dental provider states that 4 teeth are damaged with vertical cracks 
that cannot be saved. The Plan denied your request. The Plan says this service is not covered under your dental 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal 
guard  soft appliance, full arch (D9945).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the acupuncture services on July 25, 2022, to August 
08, 2022. 
 
You asked the Plan to reimburse for the acupuncture services. You say that acupuncture is an included benefit. 
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 $10 
copayment for each Medicare-covered acupuncture treatment per specialist visit. Auxiliary personnel 
furnishing acupuncture must be under the appropriate level of supervision of a physician, PA, or NP/CNS 
required by the Plan's regulations. 
 You have been asked to pay a $290 cost share for the acupuncture services. This item/service falls within the 
acupuncture for chronic low back pain 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 reimburse for the 
acupuncture services on July 25, 2022, to August 08, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xeljanz. 
 
You asked the Plan to pre-approve Xeljanz. You say that the enrollee switched to Xeljanz because the previous 
medication Olumiant was not being tolerated and it decreased their renal function. The Plan denied your 
request. The Plan says that self-administered drugs do not fall under Medicare Part B coverage. 
 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 Xeljanz.  
 
Benefits for Xeljanz 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: 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 is receiving appropriate inpatient care and is currently 
unstable for transfer to an LTACH. 
 
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 the enrollee's needs are being met in the current setting and there is no therapeutic 
advantage to a LTACH transfer. Once appropriate, the enrollee will be able to receive further services at a 
lower 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service October 7, 
2022, to November 5, 2022. You asked the Plan to pay for the billed services. You say that the NOA was billed with a Medicare # in error. 
The Plan denied your request. The Plan says the NOA was not received timely.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 7, 2022. A valid NOA was not received by the Plan until 
December 20, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for the home 
health care billed for dates of service October 7, 2022, to November 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service January 21, 2022. 
 
You asked the Plan to pay for the billed testing. You say that the claim was paid below the Medicare allowable 
amount. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
The file shows that an AlloSure Heart test was provided. We looked at the file and Medicare rules. Review of 
the claim does not show that a valid required unique identifier was reported. The test provided is not a covered 
test. Based on this information, we decided that Medicare rules for coverage of the billed testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of service 
January 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a V-front footrest, side guards, gel leg protector wraps,
luggage carrier and custom offset profiled side guards for the enrollee.

You asked the Plan to pre-approve a V-front footrest, side guards, gel leg protector wraps, luggage carrier and
custom offset profiled side guards. You say that these items are medically necessary. The Plan denied your
request. The Plan says that these items are not durable medical equipment and are not covered by Medicare.
Maximus overturned the Plan's denial. The Plan requested a reopening and stated that these items do not
qualify as durable medical equipment. The Plan is correct in this case. The rules say that for equipment to be
covered, it must primarily serve a medical purpose. The items at issue in this appeal do not serve a purpose that
is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a V-front
footrest, side guards, gel leg protector wraps, luggage carrier and custom offset profiled side guards for the
enrollee.