Persius/hicric huggingface dataset:
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 
December 6, 2021, to December 10, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the bed was the cause 
of your fall, and you should not be held responsible. 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 $275 
copayment per day, for days 1 to 6, per benefit period, for the inpatient hospital stay.  
 
 You have been asked to pay a $275 copayment per day, for days 1 to 4 of the inpatient hospital stay. You have 
been asked to pay a total of $1,100 ($275 copayment x 4 days = $1,100). 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 December 6, 2021, to December 10, 2021.
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 it is medically necessary. The Plan denied your 
request. The Plan says you 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 needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for leg 
infection and a below the knee amputation. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
You do 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 you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the practitioner services provided on November 3, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the practitioner services. You say that it was not possible to obtain authorization 
due to the place of service setting. The Plan denied your request. The Plan says care received from OON 
providers will not be covered unless 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 the practitioner services provided on November 3, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported porcelain fused metal crown 
(D6059) and custom abutment (D6057). 
 
 
You asked the Plan to pre-approve dental abutments. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
abutment supported porcelain fused metal crown (D6059) and custom abutment (D6057).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 20, 2022.
You asked the Plan to pay for procedure code 76641. You say that the records support the procedure. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation (RFA) (64633, 64634). 
 
You asked the Plan to pre-approve the RFA. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an initial thermal radiofrequency ablation (RFA) of 
cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically 
reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary 
diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index) 
pain (with the duration of relief being consistent with the agent used). 
 
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 RFA. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the member did not have 80% pain relief. 
 
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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the radiofrequency ablation (RFA) (64633, 64634).
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 IRF criteria. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post stabilization care provided on August 5, 2022, to August 
8, 2022. 
 
You asked the Plan to pay for post stabilization care. You say that this admission was medically necessary. The 
Plan denied your request. The Plan says this inpatient stay was not medically necessary. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization care. Our reviewer says 
that  Our physician reviewer found this care was not medically necessary or reasonable. The treating physician 
did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer 
on any dates of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for post stabilization care provided on August 5, 2022, to August 8, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for one crown. We decided that the Plan does not have to pay for the other 
two crowns.  
 
You asked the Plan to pay for retainer crown - porcelain/ceramic (D6740 X2) and pontic - porcelain/ceramic 
(D6245) provided on December 20, 2022.. You say that this is medically necessary.  The Plan says that only 2 
procedure codes per calendar year are covered and those were both exhausted.  
We decided that the Plan has to pay for one crown.  
 
 Therefore, we decided that the Plan has to pay for one crown.  
 
 We also decided that the Plan does not have to pay for the other two crowns. 
 
 Therefore, we decided that the Plan does not have to pay for the other two crowns. 
 
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: 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 it is medically necessary. The Plan denied your 
request. The Plan says you do not meet all 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 needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
dehydration and acute kidney injury. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
You do 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 you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on August 22, 2022 and billed under code 99213.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met as this code is included in the global payment period for code 64555 which was previously paid. The Plan states code 99213 was not billed with the appropriate modifier as an unrelated service. Maximus overturned the Plans denial because the case file lacked a copy of the claim said to have been paid for code 64555. The Plan requested a reopen and provided the required claim information.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, code 99213 cannot be paid as billed due to the omission of the required modifier to show the service is considered separate from the billing of code 64555. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for services provided to the enrollee on August 22, 2022 and billed under code 99213.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from May 21, 2022, to June 19, 2022.
You asked the Plan to pay for the home health services as billed. You say that these services were medically necessary. The Plan denied your request. The Plan says the claim 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, the home health agency (HHA) shall submit a Notice of Admission (NOA) with a one-time, artificial 'admission' date corresponding to the "From" date of the first period of continuing care in 2022. We reviewed the file and the Medicare rules. We find that the admission date reported on the NOA does not correspond to the "From" date on the NOA. Therefore, there is not a valid NOA on file. 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 May 21, 2022, to June 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to see the out-of-network 
provider because they are close to your home. The Plan denied your request. The Plan says dental services 
from an out-of-network provider are not covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental 
services provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental examination (D0120) and an adult cleaning (D1110) provided on September 22, 2022.
You asked the Plan to pay for these dental services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plans denial for a lack of information in the case file to show this benefit had been exhausted. The Plan requested a reopen and provided the required claim information.
The Plan is correct in this case. Medicare generally does not cover dental services. The Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 appealed services were exhausted on April 14, 2022. Therefore, we decided that the Plan does not have to pay for a dental examination (D0120) and an adult cleaning (D1110) provided on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture and a complete mandibular denture
You asked the Plan to pre-approve dentures. You say that you would like this to be approve by the Plan. The Plan denied your request. The Plan says that dentures are not a covered benefit. Maximus overturned the Plan's denial. The Plan requested a reopening and sent in the correct Evidence of Coverage.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture and a complete mandibular denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on September 8, 2022 and billed under code 64483.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient claim information in the case file. The Plan requested a reopen and provided the required claim information. The Plan shows the number of units billed for this code exceeds the maximum allowed by Medicare billing guidelines.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, code 64483 is not billed correctly per the National Correct Coding Initiative Policy for Medically Unlikely Edits (MUE). Code 64483 has an MUE value of 1. The claims show 2 units were billed. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on September 8, 2022 and billed under code 64483.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and lens, and the vision supply accessory 
provided on January 7, 2023. 
 
You asked the Plan to pay for the frames and lens, and the vision supply accessory. You say that you do not 
understand the partial coverage. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 with a $200 allowance and the Plan does not cover the vision supply 
accessory. 
 
We looked at the file and the Plan's rules. Specifically, the Plan applied the $200 allowance to the retail price. 
Also, the vision supply accessory is not a covered benefit. Based on this information, we decided that the Plan's 
rules for coverage of the frames and lens, and the vision supply accessory have not been met. Therefore, we 
decided that the Plan does not have to pay for the frames and lens, and the vision supply accessory provided on 
January 7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acute inpatient psychiatric hospitalization provided on 
January 1, 2022, to January 31, 2022. 
 
You asked the Plan to pay for an acute inpatient psychiatric hospitalization. You say that this admission was 
medically necessary. The Plan denied your request. The Plan says the medical criteria for an inpatient 
admission have not been met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 an acute inpatient psychiatric 
hospitalization. Our reviewer says that this admission was not medically necessary. Our physician reviewer 
found based upon review the records provided for the admission of this patient does not meet criteria for acute 
inpatient mental health treatment as this enrollee was not shown to be a danger to himself or others, no auditory 
or visual hallucinations. He is noted to be cooperative and compliant with treatment while not showing any 
aggressive behaviors. 
 
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 acute inpatient psychiatric hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pay for an acute inpatient psychiatric hospitalization provided on January 
1, 2022, to January 31, 2022.