Persius/hicric huggingface dataset:
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 requires medical/physician oversight for 
ongoing clinical conditions and active co-morbidities and will benefit from an interdisciplinary team approach 
to a rehabilitation program. 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
January 30, 2023, to January 31, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the provider refused to 
treat you because you did not have an emergency situation. 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 room visit. 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 room visit 
provided on January 30, 2023, to January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on February 21, 2023. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration for the denied claim. 
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 office visit provided on 
February 21, 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 you are requesting to admit to an acute rehabilitation 
because you was independent and active before coming to the hospital and wish to return to being independent 
as quickly as possible. 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 your 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (A4239) provided on April 7, 
2023. 
 
You asked the Plan to pay for the durable medical equipment (A4239). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.   
The record does not contain a valid physician order for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment (A4239) provided on April 7, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual swingaway (E1028), electronic connection (E2311) and power tilt (E1002)
You asked the Plan to pre-approve a manual swingaway, electronic connection and power tilt. You say that these items are medically necessary. The Plan denied your request. The Plan says that the requested accessories are not medically necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a manual swingaway, electronic connection and power tilt. Our Medical Director states that the documentation does not support that it is medically necessary to control the requested power options through the joystick (drive interface). Your upper extremity strength and functional ability as evidenced by being independent for feeding should be sufficient to control any power options through their own switches. The clinical documentation does not support that a power tilt is medically reasonable and necessary for the enrollee in this case. Our Medical Director found that your condition does not meet criteria for coverage of a manual swingaway, electronic connection and power tilt. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a manual swingaway, electronic connection and power tilt have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual swingaway (E1028), electronic connection (E2311) and power tilt (E1002)
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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the evaluation and management services to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the evaluation and management services. You say that you have been seeing 
this provider for many years. The Plan denied your request. The Plan says you must receive your care from a 
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 
the evaluation and management services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
February 13, 2023, to February 17, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. 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 $350 
copayment per day, for days 1 to 5 and a $0 copayment per day, after day 5. 
 
 
 
 You have been asked to pay a $350 copayment per day, for days 1 to 2 of the inpatient hospital stay. You have 
been asked to pay a total of $700 ($350 copayment x 2 days = $700). You have not been charged for any 
additional days. 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 the inpatient hospital stay provided from February 13, 2023, to 
February 17, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne Heme Lab testing (81455) provided on April 24, 
2023. 
 
You asked the Plan to pay for the FoundationOne Heme Lab testing (81455). You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the FoundationOne Heme Lab testing (81455) by a contract provider. The file 
does not show that the plan provided notice that the FoundationOne Heme Lab testing (81455) would not be 
covered. Under Medicare rules, this means the FoundationOne Heme Lab testing (81455) is considered 
approved by the plan. Therefore, we decided that the Plan has to pay for the FoundationOne Heme Lab testing 
(81455) provided on April 24, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on September 12, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you 
disagree with the copayment assessed and cannot afford to pay. 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 $350 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $350 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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 $160.04, which is less than the standard copayment for 
an MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance 
imaging (MRI) provided on September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral heart catheterization for the enrollee.
You asked the Plan to pre-approve bilateral heart catheterization. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee has not had any stress testing or non-invasive imaging of the coronaries.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for bilateral heart catheterization. Our Medical Director states that the enrollee's medical history included hypertension, hyperlipidemia, and squamous metaplasia of the lung. The enrollee reported shortness of breath. An echocardiogram revealed a dilated left ventricle, with preserved function and no valvulopathy. An angiogram in 2017 revealed nonobstructive coronary artery disease. Angiography (left heart with coronary angiography) was advised mostly to exclude high-risk coronary artery disease or surgical disease. The documentation does not support that bilateral heart catheterization was medically reasonable and necessary. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of bilateral heart catheterization.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral heart catheterization have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral heart catheterization for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for aminolevulinic acid for topical 
administration provided on May 01, 2023. 
 
You asked the Plan to reduce the coinsurance for aminolevulinic acid for topical administration. You say that 
you feel like you are being over-charged. 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 aminolevulinic acid for topical administration. 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 amount you owe is $70.51 ($352.53 
allowed amount x 20% = $70.51). Therefore, we decided that the Plan does not have to reduce the coinsurance 
for aminolevulinic acid for topical administration provided on May 01, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on April 21, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you could not ride in the 
ambulance since you could not leave your son at home. The Plan denied your request. The Plan says the 
Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 21, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network pharmaceutical therapy visit 
provided on April 28, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network pharmaceutical therapy visit. You say that this 
is a huge amount to pay, you were expecting a $20 copayment, not this large amount that you cannot afford. 
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 an in-network pharmaceutical therapy visit. 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 $429.68, which is the 20% coinsurance 
amount. Therefore, we decided that the Plan does not have to waive the coinsurance for an in-network 
pharmaceutical therapy visit provided on April 28, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second claim billed with procedure codes A0428 and 
A0427 provided on January 27, 2023. 
 
You asked the Plan to pay for the second claim billed with procedure codes A0428 and A0427. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says this 
claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 18, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the second claim billed with procedure codes 
A0428 and A0427 have not been met. Therefore, we decided that the Plan does not have to pay for the second 
claim billed with procedure codes A0428 and A0427 provided on January 27, 2023.  
 
We note that it appears a corrected claim was submitted directly to Maximus during the review of this case. We 
cannot act on or process claim corrections. Corrected claim information may be submitted directly to the Plan 
for further review. We are only permitted to make a decision based on the claim information reviewed by the 
Plan for payment. Please submit any corrections or additional claim information directly to the Plan.
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 out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you already had an appointment scheduled with 
the provider.  The Plan denied your request. The Plan says the enrollee may use their point-of-service (POS) 
benefits to get care from any willing Medicare provider without obtaining a referral for physician office 
services. Some Medicare providers may not be willing to see the enrollee or bill the plan for the enrollees care. 
The plan pays out-of-network providers the enrollee uses the Medicare rate for the services they provide. Prior 
authorization is not needed for office visit and the enrollee can make the appointment with a physician of their 
choice. A prior authorization may be required to determine if the service meets medical necessity. 
 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 out-of-network (OON) provider.