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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's condition does not meet the Medicare 
guidelines. The Plan says care can continue to be provided in the current 
inpatient hospital. 
 
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 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, and a take home supply of 
methadone provided on May 08, 2023. 
 
You asked the Plan to pay for medication assisted treatment, and a take home supply of methadone. You say 
that a referral or authorization is not required. 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 medication assisted 
treatment, and a take home supply of methadone provided on May 08, 2023.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after September 8, 2023.
You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from this care. The Plan denied your request. The Plan says that that it is not reasonable or necessary to continue SNF care. Maximus overturned the Plan's denial. Maximus reopened the appeal because the decision was made in error.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before September 8, 2023. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after September 8, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 22, 2023, to 
April 13, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted. The 
Plan denied your request. The Plan says the NOA has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA. Based on this information, we find that the Medicare rules for payment 
of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from March 22, 2023, to April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two dimensional (2D) oral/facial photographic image 
obtained intra-orally or extra-orally (D0350) and bitewings (D0272) provided on June 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like copies of the medical records 
and other documents the Plan used in denying your claims. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 12, 2023. Therefore, 
we decided that the Plan does not have to pay for two dimensional (2D) oral/facial photographic image 
obtained intra-orally or extra-orally (D0350) and bitewings (D0272) provided on June 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee is not a candidate for radiation 
treatments at this time due to the presence of a non-healing wound. You also say that the enrollee's PDL1 is 
high. The Plan denied your request. The Plan says this is being requested as first-line therapy. The Plan also 
says that the accepted use of this drug for the enrollee's condition requires second-line or subsequent therapy 
for disease progression on or after chemotherapy in those whose tumors express PD-L1. 
 
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 Keytruda. Our reviewer says that the requested use of Keytruda is not medically necessary. Our physician reviewer found the record indicates that 
the requested drug is being used as first line chemotherapy in an enrollee that has a diagnosis of Stage IIIB 
vulvar cancer. The Food and Drug Administration (FDA) has not stated that the requested drug is indicated for 
the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for 
the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer 
journals were submitted for review. Therefore, the reviewer found that the requested use of Keytruda 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, and a take home supply of 
methadone provided on April 17, 2023. 
 
You asked the Plan to pay for medication assisted treatment, and a take home supply of methadone. You say 
that this was the nearest facility for the enrollee to seek stabilization for their addiction distress. 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 medication assisted 
treatment, and a take home supply of methadone provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cone beam CT capture and interpretation with field 
of view of both jaws; with or without cranium (D0367). 
 
You asked the Plan to pre-approve the cone beam CT capture and interpretation. You say that the enrollee is in 
pain on tooth #6 and this is medically necessary. The Plan denied your request. The Plan says this service is not 
covered. 
 
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, the requested service Is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the cone 
beam CT capture and interpretation with field of view of both jaws; with or without cranium (D0367).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom orthotics (L3000) 
 You asked the Plan to pre-approve the custom orthotics. You say that you previously had surgery and you need 
the orthotics because your toe was amputated. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that supportive devices for the feet (such as orthotics) 
are only covered for patients with diabetic foot disease or for patients who wear a leg brace. 
 
Records show that the requested custom orthotics (L3000) are not a covered orthotic for a person with diabetes, 
and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan 
provides coverage of the requested custom orthotics. Therefore, we decided that the Plan does not have to pre-
approve the custom orthotics (L3000)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 15, 
2023, to June 22, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. 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 $230 
copayment per day for days 1-6 and a $0 copayment for days 1-90 for inpatient hospital care.  
 
You have been asked to pay a $230 copayment per day for days 1-6 and a $0 copayment for days 1-90 for 
inpatient hospital care. The total amount you owe is $1,380 ($230 x 6 days = $1,380). 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 
inpatient hospital care provided on June 15, 2023, to June 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination provided on March 21, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for radiologic examination. You say that the services should be covered. The Plan 
denied your request. The Plan says this was not authorized. 
 
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 requested 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 radiologic examination provided on March 21, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee scooter purchased on May 29, 2023. 
 
You asked the Plan to pay for a knee scooter. You say that the item should be covered. The Plan denied your 
request. The Plan says this item was purchased through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a knee scooter purchased on May 29, 
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 full criteria for an acute inpatient 
rehabilitation hospital. The Plan denied your request. The Plan says the enrollee's records do not show to have 
complex rehabilitation needs. The Plan says that the services needed may be provided safely in 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite - one surface, posterior 
(D2391) provided on June 1, 2023. 
 
You asked the Plan to pay more for the resin-based composite. You say that the service should be covered 
because you had a cavity and wasnt informed about alternative resin-based material to put in the filing. The 
Plan denied your request. The Plan says your total responsibility for the filling processed correctly in 
accordance with your plan benefits. 
 
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 resin-
based composite - one surface, posterior 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 pay for the crown. Our reviewer says that the service 
is not medically necessary. Our physician reviewer found there are no clinical records to review. Where a 
standard restoration can be placed, an amalgam or composite restoration are both viable options. The amalgam 
restoration will give a satisfactory result in virtually all cases of a one surface restoration as opposed to a 
composite restoration. Therefore, an amalgam would be appropriate and processed as the covered fee. 
 
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 resin-based composite - one surface, posterior have not been met. You are 
being charged for the less costly method, are responsible for 50% coinsurance after the $100 deductible, plus 
the difference between the allowed amounts. Therefore, we decided that the Plan does not have to pay more for 
the resin-based composite - one surface, posterior (D2391) provided on June 1, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on April 5, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee needed 
supervision for transportation to the inpatient rehabilitation admission. The Plan denied your request. The Plan 
says on this date of service the enrollee was in an inpatient status. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital it 
may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care 
while the beneficiary maintains inpatient status with the original provider.  
 
We looked at the file and Medicare rules. The records provided demonstrate that the enrollee was receiving 
inpatient hospital care at the time of the transport. This means that the transportation service furnished to the 
enrollee while they were admitted as inpatient would be covered as an inpatient hospital and not paid for 
separately under Part B. Based on this information, we decided that Medicare rules for coverage of the 
ambulance service and ground mileage have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance service, basic life support, non-emergency transport, and ground mileage provided on April 
5, 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 will receive the appropriate level of care 
in an acute rehabilitation setting. Further delay in providing this care will have a detrimental effect for safety as 
well as overall ability to recover to the fullest extent. The Plan denied your request. The Plan says the enrollee's 
condition does not meet the Medicare guidelines.  The Plan says that the services needed may be provided 
safely in 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.
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 inpatient rehabilitation is both physically and 
medically necessary for the enrollee to return home at maximum level of functioning with a decreased risk for 
readmission. The Plan denied your request. The Plan says the enrollee's records do not show to have complex 
rehabilitation needs requiring to be seen by a rehabilitation doctor three times per week. The Plan says that the 
services needed may be provided safely in 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.