Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on July 13, 2023. 
 
You asked the Plan to waive the copayment for physical therapy. You say that it was only an evaluation visit. 
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 $51.92 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $51.92 copayment for physical therapy. This item/service falls within the 
outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. You have been asked to pay $51.92 towards your deductible, as you have not met your yearly deductible at the time the claim was processed. Therefore, we decided that the Plan does not 
have to waive the copayment for physical therapy provided on July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opted-out provider on May 
23, 2023. 
 
You asked the Plan to pay for dental services. You say that this should be covered. The Plan denied your 
request. The Plan says providers who have opted out of Medicare are not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided by an opted-out provider on May 23, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on September 23, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid The Plan denied your
request. The Plan says there is insufficient information this testing was ordered by a physician and the records
provided do not establish medical necessity. Maximus overturned the Plans denial. The Plan requested a reopen
and confirmed that a call was made to the named ordering provider who indicated he did not order this testing.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient
information in the record to determine if Medicare rules for coverage of these services have been met.
Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on
September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemodenervation of larynx muscles provided on June 9, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for chemodenervation. You say that you are appealing the denial. The Plan denied 
your request. The Plan says that the original decision to deny payment was correct. 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 chemodenervation of larynx muscles provided on 
June 9, 2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the Plan erred in its denial of IRF admission. 
 
Per Medicare Benefit Policy Manual Ch 1, 110, and 42 CFR 412.622, the medical record overall complies with 
the various documentation requirements for IRF admission. This enrollees condition is in fact complex and 
fragile, but also not optimized to prove the extent of actual permanent damage they have suffered. There is 
sufficient reason to expect that the enrollee will participate in and benefit from IRF-level services to include at 
minimum PT, OT, SLP/neuropsych, physician oversight of polypharmacy, and case manager coordination of 
any additional services with outpatient providers that might be needed to make a sustainable return home with 
less supervision over time. 
 
Therefore, the requested inpatient rehabilitation facility admission is approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 22, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and noted there is no documentation that the specimen was collected from a hospital
outpatient during an encounter. The claim form listed the place of service (POS) 81, Independent Laboratory,
independent of an institution or a physician's office. Medicare rules state if an independent lab bills, the place
where the sample was taken is shown. An independent laboratory taking a sample in its laboratory shows "81"
as place of service. If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient
of a hospital, it uses the code for the inpatient (POS code 21), off campus-outpatient hospital (POS code 19), or
on campus-outpatient hospital (POS code 22), respectively. Furthermore, the exception to the General Rule
does not apply as the provider documented that the specimen was not obtained during a hospital outpatient
encounter and was obtained by the laboratory directly.
Based on the POS documented on the claim form, the date of service for a clinical laboratory test or the
technical component of physician pathology service must be the date the specimen was collected.
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 POS code. In this case, this claim
could not be paid due to an error with the reported POS code. Medicare rules for coverage of these services
have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the
enrollee on May 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy. You asked the Plan to 
pre-approve home health services. You say that the requested home health services are medically necessary.  
The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that you do not 
have documented, ongoing, home health physical therapy needs. You are functioning at a level commiserate 
with a lower level of care. As such, ongoing home health physical therapy services are not medically necessary 
or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy.
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 this request is medically necessary. The Plan denied 
your request. The Plan says based on the available information, admission to an IRF is not reasonable and 
necessary.  
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. Our reviewer also found that 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Group 3 Power wheelchair and accessories.
You asked the Plan to provide coverage for a Group 3 Power wheelchair. You say that at the time of the appeal,
the requested power wheelchair was medically necessary. The Plan denied your request. The Plan says the
Medicare coverage criteria for a Group 3 Power wheelchair were not met. Maximus overturned the Plans denial
for a lack of medical records in the file. The Plan requested a reopen and provided the required medical
records.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare requires specific diagnoses for
this type of power wheelchair and requires specific documentation in the medical record to show the required
criteria are met.
Based on the medical records provided, at the time of the appeal, you did not meet the criteria required for a
Group 3 Power wheelchair and specialized accessories. Therefore, we decided that the Plan does not have to
provide coverage for a Group 3 Power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220), resin-
based composite (D2392), crown - porcelain/ceramic (D2740), and periodic oral evaluation (D0120) provided 
on May 25, 2022, to September 28, 2022. 
 
You asked the Plan to pay for these dental services. 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 pay for intraoral - 
periapical first radiographic image (D0220), resin-based composite (D2392), crown - porcelain/ceramic (D2740), and periodic oral evaluation (D0120) provided on May 25, 2022, to September 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital level of care for cervical 
laminectomy surgery. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee desperately needs 
this surgery. The Plan denied your request. The Plan says this surgery has been approved as an ambulatory 
procedure and if the enrollee experiences any peri- or post-operative complications, reconsideration for 
inpatient level of care can be granted. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the enrollee does not meet criteria for inpatient level of care. Our physician reviewer found the 
medical team's reason for requesting inpatient level of care is not specified. The Plan's agreement to allow 
reconsideration for inpatient level of care if the enrollee develops any complications is reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital level of care for cervical laminectomy surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment  includes modification and 
placement (D6056), surgical placement of implant body: endosteal implant (D6010), radiographic/surgical 
implant index, by report (D6190), connecting bar  implant supported or abutment supported (D6055), deep 
sedation/general anesthesia  each subsequent 15 minute increment (D9223), and deep sedation/general 
anesthesia  each subsequent 15 minute increment (D9222). 
 
You asked the Plan to pre-approve the dental services. You say that this affects your entire life and your health 
as you have stomach issues because you cannot eat or chew.  
 
 You also say that you cannot enjoy life because going to a restaurant is embarrassing and your overall health is 
deteriorating and are having health issues spawning from this. The Plan denied your request. The Plan says 
these services are not covered under the benefit package.  
 
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 a 
prefabricated abutment  includes modification and placement (D6056), surgical placement of implant body: 
endosteal implant (D6010), radiographic/surgical implant index, by report (D6190), connecting bar  implant 
supported or abutment supported (D6055), deep sedation/general anesthesia  each subsequent 15 minute 
increment (D9223), and deep sedation/general anesthesia  each subsequent 15 minute increment (D9222).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF services to get stronger. The 
Plan denied your request. The Plan says the enrollee no longer meets SNF requirements. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that at the time of the appeal, skilled nursing services
were medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not
met. Maximus overturned the Plans denial. The Plan requested a reopen stating that Maximus did not apply the
correct criteria. The Plan noted that at the time of the appeal the medical records show your condition was
chronic without any acute pathophysiological or functional deterioration. You were reported to have
chronic knee pain due to severe osteoarthritis, limiting your physical ability. Your needs were custodial in
nature at that point.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care
in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. The
medical records do not show you required daily skilled nursing or daily skilled therapy services at an inpatient
level of care. Medicare rules were not met. Therefore, we decided that the Plan does not have to pre-approve
skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve care and services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve these OON services. You say that you do not have confidence in the in-
network provider due to surgical complications in 2021. The Plan denied your request. The Plan says the 
requested services can be provided by 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 
care and services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 04, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of 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 the office visit provided 
on May 04, 2023.