Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a skilled nursing facility will not provide 
adequate physician, nursing and therapy coverage and care for the enrollee's current health disposition and is 
not a candidate at this time for an acute rehabilitation and has too many medical complications at this time for a 
lower level of care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient 
acute 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 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 the enrollee is receiving appropriate care in current acute care setting as provided by the Plan. Documentation does not support that LTACH services are medically appropriate currently. The 
enrollee's records do not support the need to transfer from one acute hospital to another. 
 
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 long term acute care hospital (LTACH) services.
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 admission is medically necessary for you. The Plan 
denied your request. The Plan says your records do not show that you need to be seen by a rehabilitation 
physician at least three times a week. The Plan says services may be provided at a lower level of care.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical records 
support 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. It is not a 
reasonable expectation that you 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a total hip replacement provided on June 
26, 2023. 
 
You asked the Plan to waive the copayment for a total hip replacement. You say that you do not agree with the 
cost sharing. 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 $325 
copayment for outpatient surgery in an outpatient hospital facility. 
 
You have been asked to pay a $325 copayment for a total hip replacement. This item/service falls within the 
outpatient surgery in an outpatient hospital facility 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 a total hip replacement provided on June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99214 billed for date of service October 5, 2023. 
 
You asked the Plan to pay for 99214. You say that 99214 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 99214 is denied because the documentation does 
not support this level of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter.   
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 99214. Our reviewer says that 99214 is not 
supported in the documentation. Our reviewer found the provided documentation from this date described the 
enrollee with a red left eye. Intraocular pressure was normal, with dilated examination unremarkable. An Eylea 
injection was recommended to prevent deterioration of vision. This helped vision immediately with no reported 
complications. The enrollee was medically stable. Although the history and examination were appropriate, the 
medical decision making was not moderately complex, nor was there documentation that the duration of the 
encounter was 30-39 minutes to justify the billing of 99214. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99214 have not been met. Therefore, we decided that the Plan does not have to 
pay for the evaluation and management services described by code 99214 billed for date of service October 5, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on July 17, 2023, to September 08, 
2023. 
 
You asked the Plan to pay for a facility visit. You say that this patient is in a facility, and you depend upon the 
facility staff for any verification or prior authorization. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a facility visit provided 
on July 17, 2023, to September 08, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of iTind system. 
 
You asked the Plan to pre-approve the iTind system. You say that this is medically necessary for the enrollee. 
You also say that the enrollee is a poor surgical candidate due to cardiology or pulmonary conditions. The Plan 
denied your request. The Plan says the clinical and effectiveness of iTind System in the setting of benign 
prostatic hyperplasia (BPH) with obstruction have not been demonstrated in the peer-reviewed literature. 
 
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 iTind system. Our reviewer says 
that the requested iTind system is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has benign prostatic hypertrophy with 
hypertrophy. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested service. Therefore, the reviewer found that the requested iTind system 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 the iTind system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve placement of iTind system.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 You asked the Plan to pre-approve Aranesp. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Retacrit or Procrit. 
 
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 Aranesp. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs. The reviewer also found that there is no 
documentation provided indicating that the Plans required drug(s) would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory services provided on
February 7, 2023.

You asked the Plan to waive the deductible for the laboratory services. You say that you had bloodwork taken
during your yearly visit and do not feel a cost share should be applied. The Plan denied your request. The Plan
says this cost sharing was charged correctly. Maximus overturned the Plan's denial. The Plan requested a
reopening and stated that these services fall under the deductible. The Plan is correct in this case.

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 $300 deductible which applies to outpatient diagnostic tests and
therapeutic services and supplies.

The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $300 deductible which applies to outpatient diagnostic tests and
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time
for laboratory services was received on February 7, 2023. Therefore, we decided that the Plan does not have to
waive the deductible for the laboratory services provided on February 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injection. 
 
You asked the Plan to pre-approve sacroiliac joint injection. You say that the enrollee will benefit from the 
injection to the sacroiliac joint. The Plan denied your request. The Plan says the requested procedure is for 
sacroiliac joint injections, and Medicare guideline says that the enrollee must have a minimum of 3 positive sacroiliac joint exam tests. The provided documents of the exams indicated 2 of physical exam tests of the 
sacroiliac joint were positive, one was negative, and 3 others were not mentioned. 
 
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 sacroiliac joint injection. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found there is no documentation of at 
least three positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or Posterior Shear, 
SI Compression, SI Distraction and/or Yeoman Tests. The enrollee's provider noted positive compression and 
Gaenslen but negative FABER. The review has determined that the enrollee does not meet the indications for 
coverage for a sacroiliac joint injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac joint injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on August 
27, 2023. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you disagree with 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 $20 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for the laboratory services. 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. However, since the allowed amount is less than the 
standard copayment, you only owe $3.17. Therefore, we decided that the Plan does not have to waive the 
copayment for the laboratory services provided on August 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #23, #24, #25, and #26. 
 
You asked the Plan to pre-approve the dental services. You say that the crowns are necessary because the 
enrollee has had fillings done multiple times on the teeth and they have failed. The Plan denied your request. 
The Plan says the denial of authorization for these services is correct, because they are not covered when the 
teeth are to restore damage due to wear and grinding. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that a crown (D2740) for tooth #23, #24, #25, and #26 is not medically reasonable or necessary. Our physician 
reviewer found that the review of the x-ray shows that there are some small fillings on the edges of teeth #23, 
#24, #25, and #26. No other x-rays or photos were included. The panoramic x-ray is not a diagnostic x-ray to 
determine whether the tooth in question needs a crown. A crown procedure would require removing good tooth 
structure for a crown to be placed. The issue of why the fillings is coming off needs to be addressed, without it 
being addressed, crowns can also fracture on the biting surfaces. There may be other factors to consider why 
the fillings are failing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740) for tooth #23, #24, #25, and #26.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan tablets. 
 
You asked the Plan to pre-approve the medication. You say that this medication is necessary for hepatic 
encephalopathy. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xifaxan tablets.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital inpatient or observation care provided on 
August 22, 2023. 
 
You asked the Plan to pay for initial hospital inpatient or observation care. You say that the service should be 
covered 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 initial hospital inpatient 
or observation care provided on August 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine lab panel provided on July 27, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
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 pay for the panel. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the record indicates that the enrollee has cystitis without hematuria. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested service in the enrollee's specific 
clinical scenario. The record provided does not establish the medical necessity and reasonableness, as defined 
by Medicare rules, of the requested testing. 
 
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 panel have not been met. Therefore, we decided that the Plan does not have 
to pay for the urine lab panel provided on July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that you do not 
agree with the denial of authorization for the office visit with an OON provider. The Plan denied your request. 
The Plan says the service can be provided by an in-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 
an office visit to be provided by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the
enrollee.

You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, SNF admission
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 is correct in this case. 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.
Based on the medical records provided, at the time of the appeal, the enrollee was independent with activities
of daily living and mobility. The medical records do not show the enrollee required daily skilled nursing and/or
daily skilled therapy services at an inpatient level of care. Medicare rules for coverage of SNF care were not
met at the time of the appeal. Therefore, we decided that the Plan does not have to provide coverage for skilled
nursing facility (SNF) care for the enrollee.