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 enrollee requires IRF nursing along with intensive 
physician management of current medical conditions and risks. 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has a history of subdural hematoma in July 2023 that has resolved and a 
history of seizure disorder and is living at home with functional decline.  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.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 22, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee was in a nursing home 
at the time the services were rendered. 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 subsequent nursing 
facility care provided on August 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to the LTACH is the enrollee's 
best chance for a quicker recovery and more favorable outcome. You also say the enrollee will receive the 
individualized care plan and aggressive treatment needed to ready them for the next level of care.  The Plan 
denied your request. The Plan says the enrollee can receive the continued care they need in the current acute 
care setting.  
 
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 that the enrollee appears to require additional acute care hospital services that can safely be provided at the current facility until more stable and appropriate for transfer. There are no services at 
the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer 
to the LTACH is not medically necessary as it would not be clinically advantageous 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the hearing aids (V5261 x 2) purchased on 
July 21, 2023. 
 
You asked the Plan to waive the coinsurance for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. 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% 
coinsurance for hearing aids purchased from an out-of-network provider.  
 
You have been asked to pay $250 (Plans allowed amount of $1,000 x 25% coinsurance) for the hearing aids 
purchased from an out-of-network provider.   
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the hearing aids (V5261 x 2) purchased on July 21, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on August 25, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the services were provided prior to the 
hospice enrollment. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on August 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acupuncture treatments (97810) 
provided from June 8, 2023, through June 14, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the acupuncture 
services provided in this case are not payable as they were not rendered on the basis of a covered diagnosis.  
  
 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not 
have to issue reimbursement for the acupuncture treatments (97810) provided from June 8, 2023, through  
June 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image and mandibular tissue 
conditioning (D5851, D0330) provided on June 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 October 17, 2019 
(D0330) and June 27, 2023 (D5851). Therefore, we decided that the Plan does not have to pay for a panoramic 
radiographic image and mandibular tissue conditioning (D5851, D0330) provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on August 02, 2023. 
 
You asked the Plan to pay for a home visit. You say that this service was medically necessary. 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 
August 02, 2023.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery provided on January 27, 2023, by an out-ofnetwork
(OON) provider.

You asked the Plan to pay for the surgery. You say that this was medically necessary. The Plan denied your
request. The Plan says that this service was not authorized. Maximus overturned the Plan's denial for lack of
information. The Plan requested a reopen and provided the 2023 Evidence of Coverage.

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 surgery provided on January 27, 2023, by an
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair (E0240).  
 
You asked the Plan to pre-approve a shower chair. You say that the items should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair (E0240).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning provided on August 18, 2023. 
 
You asked the Plan to pay for advance care planning. You say that the enrollee was in a nursing home setting at 
the time services were rendered. 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 advance care planning 
provided on August 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the thoracic and 
lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee is in pain and cannot wait for 
conservative treatment. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
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 the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the documentation provided does not detail 
why an MRI of the spine is medically 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the thoracic and lumbar spine.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography  (CT) of the thorax and a CT scan of 
the soft tissue of the neck. provided on June 17, 2023. 
 
You asked the Plan to pay for computed tomography  (CT) of the thorax and a CT scan of the soft tissue of the 
neck.. You say that you are appealing based on medical necessity. 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 computed tomography  
(CT) of the thorax and a CT scan of the soft tissue of the neck. provided on June 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on August 17, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that you never received any medication's 
that you took by mouth. The Plan denied your request. The Plan says the medication is not covered as a 
medical benefit under the Plan. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
received on August 17, 2023.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from July 24, 2023, to August 22, 
2023. 
 
You asked the Plan to pay for SNF services. You say that the SNF services were medically necessary. The Plan 
denied your request. The Plan says the enrollee has reached the maximum benefit limit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from March 16, 2023, 
to July 23, 2023. The Plan has covered 100 days of SNF care.  
 
 
 Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for SNF services provided from July 24, 2023, to August 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation to a 
physician's office. 
 
You asked the Plan to pre-approve non-emergency ambulance transportation to a physician's office. You say 
that you need transportation to your medical appointment. The Plan denied your request. The Plan says 
ambulance transportation to a physician's office is not covered. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pre-approve are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pre-approve non-emergency ambulance transportation to a 
physician's office.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 sensor. You asked the Plan to pre-approve a Freestyle Libre 3 sensor. You say that your primary care provider is 
requesting you to have a Freestyle Libre 3 sensor. The Plan denied your request. The Plan says Medicare 
criteria has not been met for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin or do not 
have a history of problematic hypoglycemia.  Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 3 sensor have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre 3 sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided February 1, 2022,
through August 18, 2022.

You asked the Plan to pay for the acute inpatient level of care. You say that you are requesting a
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the acute
inpatient hospital care provided was not medically necessary.


Our Medical Director looked at the case file and the reopen request. At issue is coverage for acute inpatient
hospital care. Our Medical Director states that the enrollee has a medical history that included bipolar 1
disorder, schizoaffective disorder, and hypertension. The enrollee was brought to the hospital on February 1,
2022, with suicidal ideation. The enrollee had threatened to overdose and kill himself. He was admitted to the
hospital with dehydration and hyponatremia. The plan was to remain in the hospital until medically clear and
accepted in transfer to a psychiatric facility. Psychiatry determined that the enrollee would likely benefit from
inpatient psychiatric hospitalization for medication, mood stabilization, and safe discharge planning. He was to
remain in the hospital with monitoring for safety pending acceptance into an inpatient psychiatric facility or
until further evaluation found him to be stable and appropriate for discharge. On February 9, 2022, it is
documented that the legal hold was lifted, and the psychiatry team signed off. On February 9, 2022, neurology
documented an acute mental status change, with evidence of a subacute infarct in the left posterior cerebral
artery (PCA) distribution. "Acute infarct likely responsible for current cognitive changes including memory
loss, speech difficulty and what I believe is right homonymous hemianopsia." On February 10, 2022, and
February 11, 2022, it is documented that the enrollee was medically stable for discharge. It is noted that the
enrollee "would benefit from post-acute placement at skilled versus rehab." Case management was working on
placement. The enrollee agreed to go to a skilled nursing facility (SNF), but the barrier to discharge was that
there was no accepting SNF at that time. Placement remained an issue. The enrollee was ultimately discharged
to a SNF on August 18, 2022. The available documentation supports that the enrollee was medically stable for
discharge on February 11, 2022. The enrollee could have been transitioned to an outpatient level of care at that
time. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of acute
inpatient level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the acute inpatient level of care have not been met. Therefore, we decided that
the Plan does not have to pay for the acute inpatient hospital care provided February 1, 2022, through August
18, 2022.