Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration (D4266 and D4267) for 
tooth #4 and #12, (D4277) for tooth #4, the gum graft procedure (D4278) for tooth #5 and #6, the surgical 
placement of implant body (D6010) for tooth #2, #6, #10, #12, an interim abutment (D6051) for tooth #10, a 
prefabricated abutment (D6057) for tooth #4, #6, #10, and #12, an abutment supported to crown (D6059 and 
D6061) for tooth #4, #6, and #10, an implant supported to crown (D6066) for tooth #12, a provisional implant 
crown (D6085) for tooth #10, a bone graft (D6104) for tooth #10, and a pontic (D6242) for tooth #5. 
 
You asked the Plan to pre-approve the dental services. You say that it is necessary that you have the dental 
services completed. The Plan denied your request. The Plan says the denial of authorization for the pontic is 
correct because you are missing multiple teeth. Also, the guided tissue regeneration, the gum graft procedure, 
and the dental implants along with the associated services are not covered by the 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. 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 the pontic (D6242) for tooth #5 is not medically necessary. Our physician reviewer found that the 
documentation indicates that the implant services indicated above are not covered under the plan. Due to the 
multiple missing posterior teeth in the maxillary arch, a fixed prosthesis replacing missing tooth #5 with a 
pontic (D6242) does not meet the criteria for coverage. 
 
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 pontic have not been met. The guided tissue regeneration, the gum graft 
procedure, and the dental implants along with the associated services are not covered under the Plans dental 
benefit. Therefore, we decided that the Plan does not have to pre-approve the guided tissue regeneration 
(D4266 and D4267) for tooth #4 and #12, (D4277) for tooth #4, the gum graft procedure (D4278) for tooth #5 
and #6, the surgical placement of implant body (D6010) for tooth #2, #6, #10, #12, an interim abutment 
(D6051) for tooth #10, a prefabricated abutment (D6057) for tooth #4, #6, #10, and #12, an abutment supported 
to crown (D6059 and D6061) for tooth #4, #6, and #10, an implant supported to crown (D6066) for tooth #12, 
a provisional implant crown (D6085) for tooth #10, a bone graft (D6104) for tooth #10, and a pontic (D6242) 
for tooth #5.
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 would benefit from this care. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the criteria for an IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs these services to get stronger. The 
Plan denied your request. The Plan says the services you need can be provided safely in other settings.  
 
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 the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation.  The enrollees care needs can be met 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 pre-approve an epidural injection with moderate sedation. 
 You asked the Plan to pre-approve the injection with moderate sedation. You say that you felt pain relief after 
the first injection, but the relief was short-lasting. You say that your pain continued since the first injection, and 
it is interfering with daily activities.  The Plan denied your request. The Plan says an epidural steroid injection 
with moderate sedation 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 pre-approve the injection with moderate sedation. 
Our reviewer says that an epidural injection with moderate sedation is not medically necessary. Our physician 
reviewer found that you never had three months of significant improvement after the three previous injections. 
Also, you have not actively participated in a home exercise program or a rehabilitation program. Therefore, the 
request is not medically reasonable and 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 injection with moderate sedation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an epidural injection with moderate sedation.
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 you are walking with a crutch, your body weight 
went down and you need to gain about 40 pounds. You also say that you would like to get back to your 
previous self and rehabilitation would help you to get back walking without a walker. The Plan denied your 
request. The Plan says based on Medicare guidelines, the inpatient rehabilitation facility services you are 
requesting do not meet the requirements for approval.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found The complexity of your nursing, medical and rehabilitation can be provided in a 
lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can be provided 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation.

You asked the Plan to provide coverage for additional routine transportation. You say that the Plan denied
your request. The Plan says this benefit has been exhausted. Maximus overturned the Plans denial for a lack of
claim information in the case file to show all trips had been used. The Plan requested a reopen and provided the
required information.

The Plan is correct in this case. 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 Plan's
coverage rules apply in this case. The Plan covers a maximum 12 of trips per year. We looked at your request,
the records in the case file, and the rules. Based on this information, we decided that you have exhausted the
Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not
have to provide coverage for additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for special supplemental benefits for the
chronically ill (SSBCI).

You asked the Plan to provide coverage for SSBCI benefits. The Plan denied your request. The Plan says the
medical records do not show you meet the required criteria. Maximus overturned the Plans denial because a
Plan contract was not included in the case file. The Plan requested a reopen and provided the required contract.

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 clearly says you must meet specific criteria for SSBCI
benefits to be covered. The records provided from you physician do not show you meet these criteria.
Therefore, we decided that the Plan does not have to provide coverage for special supplemental benefits for the
chronically ill (SSBCI).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy (PT) home health visits. 
 You asked the Plan to pre-approve the continued PT visits. You say that you need the requested home health 
care services due to your health issues. The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the continued PT visits. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the provided 
records in this case document that you have improved your walking distance from 50 feet with stand-by 
assistance to 200 feet with a wheeled walker with independence and that you are now independent for transfers 
and activities of daily living. Based on the available records you appear to have improved with therapy. After 
the physical therapy treatments provided, records do not support that the complexity of your condition is such 
that the skills of a professional therapist are required to achieve further improvement in your symptoms or 
functional status. Further utilization of the home exercise program appears appropriate at this point. 
 
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 continued PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued physical therapy (PT) home health visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional home health physical therapy (PT) 
visits (G0151, G0152). 
 You asked the Plan to pre-approve additional home health services. You say that you are requesting 
reconsideration due to medical necessity. The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additional home health services. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
clinical documentation shows that all reasonable home health physical therapy goals have been completed 
(including stair and medical equipment training) thus the records do not show that 6 additional home health 
physical therapy sessions are required to effectively provide treatment, care, and/or services in order to improve 
the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level 
of function and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve six (6) additional home health physical therapy (PT) visits (G0151, 
G0152).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a flex-walk system or equal (L5981) for the
enrollee.

You asked the Plan to provide coverage for a flex-walk system or equal (L5981). You say that at the time of
the appeal, a flex-walk system or equal (L5981) was medically necessary. The Plan denied your request. The
Plan says the actual medical records do not reflect the enrollee is a K3 ambulator. Maximus overturned the
Plans denial stating the enrollee had the potential to be a K3 ambulator. 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. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. The medical records provided by the physician did not confirm the statements
made by the prosthetist that at the time of the appeal, the enrollee was a K3 ambulator. Having the potential to
achieve the level of a K3 ambulator does not qualify for coverage. We looked at the file and Medicare rules.
Based on this information, we decided that there is insufficient information in the record to determine if
Medicare rules for coverage of a flex-walk system or equal (L5981) were met at the time of the appeal.
Therefore, we decided that the Plan does not have to provide coverage for a flex-walk system or equal (L5981)
for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a driver's license renewal evaluation. 
 
You asked the Plan to pre-approve driver's license renewal evaluation. You say that you want to renew your 
expired license. The Plan denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that examinations required by government agencies 
are not covered.  
 
We looked at the file and Medicare rules. A routine examination for the purposes of drivers licensure is not 
covered by Medicare because it is a requirement of a government agency. Based on this information, we 
decided that Medicare rules for coverage of driver's license renewal evaluation have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a driver's license renewal evaluation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic respiratory 
failure from chronic obstructive pulmonary disease (COPD). She has not failed bi-level positive airway 
pressure (BiPAP) therapy with average volume-assured pressure support (AVAPS). The criteria for coverage 
are not met and the portable ventilator is not medically necessary at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen equipment provided from
August 15, 2021, to September 15, 2022.

You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you do not understand
why the COVID-19 oxygen equipment is not covered at 100%. The Plan denied your request. The Plan says
this cost sharing was charged correctly. Maximus overturned the Plan's denial for a lack of information. The
Plan has requested a reopening and stated that the enrollee was charged correctly. The Plan is correct in this
case. The EOC's for both 2021 and 2022 indicate a 20% coinsurance is due for durable medical equipment.
You have been asked to pay a 20% coinsurance for the oxygen equipment. This item/service falls within the
Durable medical equipment (DME) and related 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 coinsurance for the oxygen equipment provided from August 15, 2021, to September 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid repairs provided on January 9, 2023.

You asked the Plan to pay for the hearing aid repairs. You say that you are requesting a reconsideration of the
Plan's denial for payment. The Plan denied your request. The Plan says that the service at issue is not payable
as it was rendered by an out-of-network provider. Maximus overturned the Plan's denial because of a lack of
information. The Plan requested a reopening and stated that per the EOC these services were not covered. The
Plan is correct in this case. The EOC clearly states that routine hearing services are not covered when provided
by an out-of-network provider. These services were provided by a non-network provider. Therefore, we
decided that the Plan does not have to pay for the hearing aid repairs provided on January 9, 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 the enrollee meets Medicare Criteria for Acute 
Inpatient Rehabilitation and will benefit from Acute Inpatient Rehabilitation that cannot be accomplished at a 
lower level of care. The Plan denied your request. The Plan says the enrollee's condition does not meet all of 
the requirements for inpatient rehabilitation admission. 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.