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

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF is medically necessary. The Plan denied your 
request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower 
level of care such as a skilled nursing facility. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found you have a medical history of hypertension, hyperlipidemia, diabetes mellitus type II, Charcot foot, and 
obstructive sleep apnea. You were admitted to the hospital for a non-healing right diabetic foot ulcer and 
osteomyelitis that required a right sided transtibial amputation.  Given your medical conditions and need for 
pain control and monitoring of your amputation site, you would benefit from the oversight of a rehabilitation 
physician and rehabilitation nursing care. Your medical and rehabilitation needs do require the intensive 
interdisciplinary approach provided on acute inpatient rehabilitation. You require minimal assistance with 
transfers, mobility, and daily activities. You have had a significant decline from your baseline level of function 
and would benefit from the intensity of therapies provided on acute inpatient rehabilitation. You would also 
benefit from being assessed by prosthetics in terms of his level of ambulation and need for a prosthesis. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 pre-approve a magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says the medical records 
do not show enrollee was compliant with a home exercise program and declined physical therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the medical records do not show that the 
enrollee was compliant with a home exercise program, declined physical therapy and are no abnormal 
neurological findings noted. The requested MRI of the lumbar spine for the enrollee 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 an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a magnetic resonance imaging (MRI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sprint PNS system.  
 
You asked the Plan to pre-approve the sprint PNS system. The Plan denied your request. The Plan says the 
sprint PNS system 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 sprint PNS system. Our reviewer 
says that the sprint PNS system is not medically necessary. Our physician reviewer found that the sprint PNS 
system is not an implanted peripheral neurostimulator with a trial of implantation showing effective pain 
control. Furthermore, the device does not meet the Medicare criteria as the device has not been shown to be 
effective in the medical literature. Therefore, the sprint PNS system 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 sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the sprint PNS system.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional one-way trips. 
 
You asked the Plan to pre-approve one-way trips. You say that you need more transportation. The Plan denied 
your request. The Plan says this benefit has been exhausted. 
 
  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 a maximum of 32 one-way 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 pre-approve additional one-way trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visit (99203) provided on March 3, 
2023. 
 
You asked the Plan to reimburse you for the physician service. You say that this provider performed the 
surgery you had a few years ago. You say that other doctors misdiagnosed you for a year and a half. You also 
say that you felt that you had no other option but to go back to this provider. The Plan denied your request. The 
Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made 
for services performed by a provider that has opted out of Medicare. 
 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 reimburse you for 
the office visit (99203) provided on March 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline of a complete lower denture (indirect) (D5751) 
provided on August 3, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service December 9, 2022.  
  
 
Specifically, the Plans contract states that a reline of a complete lower denture (indirect) (D5751) and 
associated services are covered once every twelve months. You previously received a reline of a complete 
lower denture (direct) (D5731) on December 9, 2022, less than twelve months prior, which was paid for by the 
Plan. This is an associated service. Therefore, you have exhausted the allowable benefit for the service 
provided in this case. Therefore, we decided that the Plan does not have to pay for the reline of a complete 
lower denture (indirect) (D5751) provided on August 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided on April 12, 2023, with an out-of-network 
provider. 
 
You asked the Plan to pay for services provided on April 12, 2023, with an out-of-network provider. You say 
that you want the Plan to reimburse you for these services. The Plan denied your request. The Plan says based 
on a lack of information submitted, we are unable to determine that the services were considered urgent or 
emergent in nature. Services received with an out of area provider would need to be considered urgent or 
emergent to qualify for coverage or prior authorization would need to be provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 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 services provided on April 12, 2023, 
with an out-of-network provider have been met. There are no medical records within the casefile. Without the 
requested clinical information, we are unable to determine if the requested services are medically necessary. 
Therefore, we decided that the Plan does not have to pay for services provided on April 12, 2023, with an out-
of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an LDCT scan for lung cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee meets the criteria for 
the requested imaging. The Plan denied your request. The Plan says criteria for an LDCT scan have not been 
met. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee is not between 50-77 years of age. 
Therefore, we decided that the Plan does not have to pre-approve an LDCT scan for lung cancer screening.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit (99284, 
99281) provided on August 18, 2023. 
 
You asked the Plan to waive the copayment for the emergency department visit (99284, 99281). You say that 
you should not be responsible for a 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency department visit (99284, 99281). 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 department visit (99284, 99281) provided on August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on May 19, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that this provider became participating on April 5, 
2023, before the date of service. You also say that this should be reprocessed for payment. The Plan denied 
your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided on May 19, 2023, 
by an out-of-network (OON) provider.
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 an IRF admission to 
improve overall functional mobility and safety prior to returning home. The Plan denied your request. The Plan 
says an IRF admission is not medically necessary, but skilled therapies as an outpatient, at home with home 
health care, or at a long term care facility may be approved upon request.  
 
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. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports 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. There is not a reasonable expectation that the enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on May 22, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
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 home visit provided on 
May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on June 23, 
2023. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that the cost share is wrong. 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 $25 
copayment for urgently needed services. 
 
You have been asked to pay a $25 copayment for the urgent care visit. This item/service falls within the 
urgently needed 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 the urgent 
care visit provided on June 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for therapeutic injections provided on June 
29, 2023. 
 
You asked the Plan to reduce the coinsurance for therapeutic injections. You say that you feel you are being 
robbed with these copays. Your provider told you that you should only owe $20. You cannot afford something 
over $500. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for therapeutic injections. This item/service falls within the 
Medicare Part B prescription drugs 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. The total you owe is $505.60 ($2,528 x 20% = $505.60). Therefore, we decided 
that the Plan does not have to reduce the coinsurance for therapeutic injections provided on June 29, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that the drug is medically necessary for the enrollee's 
treatment for anemia. The Plan denied your request. The Plan says Retacrit is an off-label use that is not 
medically accepted for the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Retacrit. Our reviewer says that the 
drug requested does not meet the criteria necessary for approval. Our physician reviewer found that Retacrit is 
not FDA-approved for the enrollee's diagnosis and the requested use is not supported by one of the major drug 
compendia or by clinical research. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92004), frames (V2020), and bifocal lens 
(V2200) provided on July 28, 2023, by a non-Plan approve vision care provider. 
 You asked the Plan to pay for the eye exam, frames, and bifocal lens. You say that you are requesting a 
reimbursement. The Plan denied your request. The Plan says the treating provider was not contracted to 
provide vision services or vision eyewear for your benefit plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are provided by Plan-approved vision or Plan network 
providers. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you received these items and 
services from a provider that is not a Plan-approved vision care provider. Based on this information, we 
decided that the Plan's rules for coverage of the eye exam, frames, and bifocal lens have not been met. 
Therefore, we decided that the Plan does not have to pay for the eye exam (92004), frames (V2020), and 
bifocal lens (V2200) provided on July 28, 2023, by a non-Plan approve vision care provider.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the
services are medically necessary. The Plan denied your request. The Plan says that an IRF admission is not
medically necessary. Maximus overturned the Plan's 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 IRF admission is
covered only when it is medically reasonable and necessary as described in the Medicare rules section. The
rules are clear that you must meet specific criteria prior to admission for IRF care to be covered. The records
clearly show that at the time of the appeal prior to admission the enrollee did not meet all the criteria required
by Medicare for coverage. Therefore, we decided that the Plan does not have to pre-approve acute inpatient
rehabilitation facility (IRF) admission and services for the enrollee.