Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis (code 74178). 
 
You asked the Plan to pre-approve the CT scan. The Plan denied your request. The Plan says the service is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
criteria for coverage has not been met. Our physician reviewer found the enrollee had a negative CT abdomen 
and pelvis for possible abdominal mass on November 27, 2022. During the most recent encounter of June 27, 
2023, the abdominal exam was negative, and the enrollee had no abdominal complaints. No abnormal lab 
values have been presented. The medical necessity of the requested CT abdomen and pelvis has not been 
established in the submitted records. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (code 74178).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erbitux. 
 
You asked the Plan to pre-approve Erbitux. You say that the requested drug is medically necessary, and you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 
requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Erbitux. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found the requested use of Erbitux not FDA 
approved for the enrollee's diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Erbitux have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Erbitux.
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 enrollee will clearly benefit from acute 
rehabilitation to optimize her level of functioning prior to returning home.  The Plan denied your request. The 
Plan says the enrollee does 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 enrollee does not require and cannot benefit from intensive therapy. The enrollee 
is markedly deconditioned and will need a prolonged course of rehabilitation. As intensive rehabilitation is not 
indicated post hip fracture, and the enrollee has evidence of sarcopenia which limits her response to therapy.  
 
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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve PBRT. 
 
You asked the Plan to pre-approve PBRT. You say that the requested PBRT is medically necessary. The Plan 
denied your request. The Plan says that the requested PBRT is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 PBRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the cardiac exposure is markedly better with proton therapy. This is in part due to how the 
target volumes are defined (they extend very medially) as well as not using other cardiac sparing techniques 
such as deep inspiration breath hold which would push the heart somewhat out of the radiation beams. Thus, 
this is a challenging case, as the need for proton therapy is justifiable with dosimetric comparison showing a 
clinically meaningful reduction in cardiac exposure, but arguably with inferior planning of the non-proton-
based plan. Nevertheless, with a dosimetric benefit shown, the need for proton therapy is demonstrated and that 
proton therapy would be accepted as a standard approach when non-proton plans excessively dose the heart. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have been met. Therefore, we decided that the Plan has to pre-approve 
PBRT.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for ongoing treatment of 
breast cancer. 
 
You asked the Plan to pre-approve the referral. You say that continued care to completion is medically 
recommended. The Plan denied your request. The Plan says there is an approval for an in-network plastic 
surgeon. 
 
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 the referral. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation for why the enrollee would need to see an out-of-network plastic surgeon. 
No prior plastic surgery consultation is provided. The surgical notes only states plan for mastectomy and lymphoscintigraphy, which presumes any plastic surgery will be done later. An in-network plastic surgeon is 
available. The service 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 the referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an out-of-network referral for ongoing treatment of breast cancer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services billed with Health Insurance 
Prospective Payment System (HIPPS) code 3IA11 provided from April 9, 2022, to May 4, 2022.  
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the recertification based on the primary diagnosis is not supported 
in the documentation. 
 
The Plan must follow Medicare rules. The rules say that certain data elements are required for home health 
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 pay for the home health services. Our reviewer says 
that the criteria have not been met. Our reviewer found the documentation doesnt support the correct Patient-
Driven Grouping Model (PDGM) HIPPS code was submitted by the organization. The documentation indicates 
that the primary diagnosis code was not represented in the clinical documentation received. The primary 
diagnosis code of E11.9 (Type 2 diabetes mellitus without complications) did not appear to be related to the 
skilled services. The documentation available for review does not support that skilled services were received 
during this period of time. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services billed with Health Insurance Prospective Payment System 
(HIPPS) code 3IA11 provided from April 9, 2022, to May 4, 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 enrollee needs to go to an inpatient facility due to 
mobility purposes and overall well-being. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare 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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement; however, the documentation 
does not support that the enrollee would meet criteria for admission to an acute inpatient rehabilitation facility. 
There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab 
services 15 hours a week, under the supervision of a physician with at least three visits weekly to regain or 
maintain functional status. The enrollee can 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 rendered on February 13, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says these codes are not appropriate for the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report describes 
outpatient intravenous insulin treatment. In this case, there is a more appropriate code to report for these 
services.  
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 procedure codes 96365 and 96366 rendered on February 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ruxience.  
 
You asked the Plan to pre-approve Ruxience. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Ruxience. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the addition of Ruxience in impacting 
outcomes of CNS lymphoma is unclear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ruxience have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ruxience.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the fundus photography provided on February 13, 2023. 
 
You asked the Plan to hold you harmless for the fundus photography. You say that the provider was in-
network, and you should be reimbursed. The Plan denied your request. The Plan says that the service is not 
covered under your supplemental benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan did not submit a claim form or medical records showing the 
diagnosis code. Though the Plan lists out the diagnosis code, Maximum is unable to verify if this is the correct 
diagnosis code. In addition, the Plan indicated that the service is not covered, but the service was rendered by a 
network provider, without any evidence that there was a clear exclusion of coverage that was explained to the 
enrollee at the time of service. Due to the missing information, we decided that the Plan has to hold you 
harmless for the fundus photography provided on February 13, 2023.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on January 10, 2023, billed 
with codes 99204 74240, 74230, 92611, 72040, 70100, and 70310. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. The service provided is a barium swallow study 
and includes the administration of a substance to the patient. Therefore, we decided that the Plan does not have 
to pay for radiological services provided on January 10, 2023, billed with codes 99204 74240, 74230, 92611, 
72040, 70100, and 70310.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) visit 
provided on February 1, 2023. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you do not feel this "visit" was worth 
the copayment. You were assessed, given a bracelet, then told to sit and wait to be called. I was waiting so long 
that I left. 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 $75 
copayment for emergency services.  
 
You have been asked to pay the allowed amount of $70.55 which is less than the $75 copayment for an ER 
visit. This item/service falls within the emergency services 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 an in-network emergency room (ER) visit provided on 
February 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network laboratory test and a 
myocardial perfusion imaging provided on February 11, 2022, and March 25, 2022. 
 
You asked the Plan to waive the copayment for an in-network laboratory test and a myocardial perfusion 
imaging. You say that you were totally shocked by this large bill. You should not owe this much money for 
these tests. 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 other Medicare-covered laboratory tests that are not FIT tests, and a $325 for other Medicare-
covered diagnostic radiology services that are not ultrasounds ($10 +$325 = $335).  
 You have been asked to pay a $335 copayment for to waive the copayment for an in-network laboratory test 
and a myocardial perfusion imaging.  
This item/service falls within the other Medicare-covered laboratory tests that are not FIT tests, and other 
Medicare-covered diagnostic radiology services that are not ultrasounds 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 an in-network laboratory test and a myocardial perfusion imaging 
provided on February 11, 2022, and March 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient stay provided from 
March 7, 2023, to March 13, 2023.  
 
You asked the Plan to waive the copayment for an in-network inpatient stay. You say that you should not have 
an upcharge for a private room and want the Plan to pay the entire cost. 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 $320 
copayment per day, for days 1 - 5 for inpatient hospital care.  
 
You were in the hospital for 5 days, resulting in a $1,600 total copayment ($320 x 5 = $1,600). You have been asked to pay a $1,600 copayment for an in-network inpatient stay. 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 an in-
network inpatient stay provided from March 7, 2023, to March 13, 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 your current condition demands immediate and 
intensive rehabilitation to regain your independence and quality of life. The Plan denied your request. The Plan 
says you do not meet the requirements for coverage. 
 
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 that, as your needs are primarily custodial, pending resolution of your weight bearing 
status, you do not require complex or intensive rehabilitation to address metacarpal fractures. 
 
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.