Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider. 
 
You asked the Plan to pre-approve physical therapy. You say that the in-network facility does not have the 
safety equipment required. The Plan denied your request. The Plan says the enrollee must receive care from a 
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The 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 
physical therapy to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the specialist visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the specialist visits. You say that you need to continue seeing the same 
provider after surgery. The Plan denied your request. The Plan says you must receive your care from a network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The 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 
the specialist visits 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 pay for outpatient surgery provided on January 31, 2023. 
 
You asked the Plan to pay for outpatient surgery. You say that you say that you dont have the money to cover 
the cost. 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 outpatient surgery 
provided on January 31, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging provided 
on December 16, 2022. 
 
You asked the Plan to waive the copayment for the magnetic resonance imaging. You say that you say that you 
cannot afford the copayment. 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 $300 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $300 copayment for the magnetic resonance imaging. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies 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 magnetic resonance imaging provided on December 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 You asked the Plan to pre-approve the additional routine transportation miles. You say that you need to go to 
dialysis three times per week and this is a life or death situation. You also say that you do not have any means 
of transportation to get you to your appointments. The Plan denied your request. The Plan says the requested 
additional transportation miles exceed the limit of the supplemental benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when you receive 48 non-emergency transportation trips via 
contracted transportation providers to plan-approved locations to receive health care services from network 
providers There is a 50-mile limit per trip. Available modes of transportation include taxi, van, medical 
transport, or rideshare services.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional routine transportation miles.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 5, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says you got the service 
from a provider who chose not to receive Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided on July 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the diabetic shoes and inserts provided on 
January 4, 2023. 
 
You asked the Plan to waive the deductible for the diabetic shoes and inserts. You say that the shoes and inserts 
should be fully covered. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to diabetes self-management training, 
diabetic services and supplies. Your contract with the Plan also clearly says that you must pay a $10 copayment 
once the deductible has been met for diabetic shoes and inserts. 
  
 
 You have been asked to pay a total of $282.08 towards your deductible for the shoes and the inserts. The items 
or services you asked the Plan to waive the deductible for fall within the diabetes self-management training, 
diabetic services and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $750 deductible which applies to diabetes self-management training, diabetic 
services and supplies. This cost sharing is a contractual obligation that had not been met at the time the diabetic 
shoes and inserts was received on January 4, 2023. Therefore, we decided that the Plan does not have to waive 
the deductible for the diabetic shoes and inserts provided on January 4, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve physical therapy services. You say that the OON provider is the only 
provider that provides the type of therapy you need. The Plan denied your request. The Plan says you must 
receive your care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The 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 
physical therapy services to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve pain management. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollee must get their care from network providers. Usually, the 
plan will not cover care from a provider who does not work with the health plan. 
 
 
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 
pain management to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sleep study to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve sleep study. You say that you want to have the prior authorization 
overturned because you do not want to be billed for the services. The Plan denied your request. The Plan says if 
medically necessary specialized services are not available from a provider in the plan network, the enrollee 
may get these services from an out-of-network provider. The enrollees primary care provier (PCP) is 
responsible for submitting the request for prior authorization for out-of-network 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 
sleep study to be provided by an out-of-network (OON) provider.
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 
October 31, 2022, to November 4, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that due to a mistake made 
during surgery you had to stay in the hospital. 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 $125 
copayment per day, for days 1 to 6 and a $0 copayment after day 6 for inpatient hospital care.  
 
 You have been asked to pay a $125 copayment for days 1 to 4 of the inpatient hospital stay. You have been 
asked to pay $500 ($125 copayment x 4 days = $500). 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 October 31, 2022, to November 4, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 30, 2023. 
Therefore, we decided that the Plan does not have to pay for the dental services on January 30, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient hospital services provided on September 23, 2022. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. In this case, the Plans sole rationale for denial is that it 
claims that the services in dispute should be covered by the patients Workers Compensation insurance. 
However, the Plan has provided absolutely no documentation regarding the claim sent to Workers 
Compensation. The Plan has provided no documentation showing what Workers Compensation determined 
was the actual injury for which there may be coverage. The burden is on the Plan to show why its denial was 
correct. In this case, the Plan has failed to provide evidence of any communications, documentation, or 
explanation as to the Workers Compensation denial and the extent of coverage potentially available under that 
program. Without this information, we cannot determine if the claim should legitimately be paid by Workers 
Compensation or by the Plan. Therefore, we decided that the Plan has to pay for the outpatient hospital services 
provided on September 23, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH level of 
care to better their health. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee's needs can be met in another setting. 
 
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 the 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 enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room service provided on 
January 01, 2023. 
 
You asked the Plan to waive the copayment for the emergency room service. You say that you received 
minimal care from the provider. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room service. This item/service falls within 
the emergency 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 emergency room 
service provided on January 01, 2023.
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 
February 5, 2023, to February 7, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be held 
responsible for the copayment. 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 $125 
copayment per day, for days 1 to 10 and a $0 copayment per day, starting with day 11 for inpatient hospital 
care.  
 You have been asked to pay a $125 copayment for day 1 of the inpatient hospital stay. 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 February 5, 2023, 
to February 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing billed with code 83789 for date(s) of 
service December 14, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for laboratory testing billed with 
code 83789 for date(s) of service December 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the associated acute inpatient hospital admission and 
care. 
 
You asked the Plan to pre-approve associated acute inpatient hospital care. You say that the enrollee has a 
condition which places them at risk for post anesthesia respiratory paralysis. You say that the enrollee is on 
blood thinners. You also say that the enrollee is afraid of not being in the hospital. The Plan denied your 
request. The Plan says the requested inpatient admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 associated acute inpatient hospital care. 
Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in 
this case. Our physician reviewer found the enrollee is undergoing a planned total right hip arthroplasty and 
removal of implant. The reviewer found that the enrollee is medically stable and has been provided medical 
clearance to undergo this elective procedure. The planned procedure listed under procedure codes 27130 and 
20680 are not listed on the Centers for Medicare and Medicaid Services (CMS) Inpatient Only List. The 
procedure is currently approved as an ambulatory procedure. The reviewer also found that the documentation 
does not support that there is an expectation the enrollee will require a greater than 2 midnight stay. Therefore, 
the reviewer found that the requested inpatient admission is not medically reasonable or 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 associated acute inpatient hospital care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the associated acute inpatient hospital admission and care.