Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy provided on September 
14, 2023. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you would like for this service to 
be fully covered. 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 $250 
copayment for outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $250 copayment for the colonoscopy. This item/service falls within the 
outpatient surgery, including services provided at ambulatory surgical centers 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 colonoscopy provided on September 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466).  
 
You asked the Plan to pre-approve a ventilator. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says noninvasive ventilators (NIVs) used as respiratory assist devices 
(RAD) are not considered reasonable or necessary. The Plan also says there are no documented values of 
chronic respiratory failure on the enrollee's arterial blood gas.  
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator. Our reviewer says that the 
requested ventilator is not medically necessary. Our physician reviewer found the provided records indicate a 
diagnosis of chronic respiratory failure with obesity hypoventilation syndrome and thoracic restrictive disease. 
The reviewer found that the records indicate that the home ventilator is being requested for use in a pressure 
support with target tidal volume mode which is a modality that could be provided by a bilevel positive airway 
pressure (BiPAP) device with average volume assured pressure support (AVAPS) and a back-up rate. Provided 
records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. Therefore, the 
reviewer found that the requested ventilator is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient audiology visit provided on 
July 20, 2023. 
 
You asked the Plan to waive the copayment for the outpatient audiology visit. You say that you are requesting 
reconsideration of 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 $200 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $200 copayment for the outpatient audiology visit. This item/service falls within 
the in-network outpatient hospital 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. However, since the allowed amount is less than the standard copayment, 
you only owe $128.09 Therefore, we decided that the Plan does not have to waive the copayment for the 
outpatient audiology visit provided on July 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebroplasty. 
 
You asked the Plan to pre-approve a percutaneous vertebroplasty. You say that the enrollee is in pain and has 
been trying to get this procedure since the beginning of the year. The Plan denied your request. The Plan says 
the request is not medically necessary because the records do not show the enrollee has worsening pain or 
failure of non-surgical medical management. 
  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a percutaneous vertebroplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no trial and failure of bracing for fracture treatment. 
 
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 percutaneous vertebroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a percutaneous vertebroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by a cardiology specialist. 
 
You asked the Plan to pre-approve the requested services. You say that your heart beats very fast unexpectedly. 
The Plan denied your request. The Plan says a referral is required. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that your PCP coordinates covered services including care from specialists. 
 
 
 The requested provider in this case is a network specialist. The care file does not show that a referral has not 
been submitted for the requested services as required. We found no exception that would require the Plan to 
pre-approve these requested services at this time. Therefore, we decided that the Plan does not have to pre-
approve an office visit to be provided by a cardiology specialist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for teeth #20 and #28, a custom 
fabricated abutment (D6057) for tooth #31, an endosteal implant (D6010) for tooth #31, and an abutment 
supported crown (D6058) for tooth #31. 
 
You asked the Plan to pre-approve the dental services. You say that this dental work is medically necessary. 
The Plan denied your request. The Plan says these services have been correctly denied. 
 
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 D2750 for teeth #20 and #28 was exhausted on date of service October 29, 2020. This 
benefit does not include D6057, D6010, or D6058. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for teeth #20 and #28, a custom fabricated abutment (D6057) for tooth #31, an 
endosteal implant (D6010) for tooth #31, and an abutment supported crown (D6058) for tooth #31.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health services. 
 You asked the Plan to pre-approve home health services. 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 the records 
show the enrollee is medically stable, does not require wound care, catheterization, G-tube feeding, or 
administration of IV or complex medications. The most recent surgeries were performed on an outpatient basis, 
and the enrollee has not recently been hospitalized. The enrollee and the caregiver have been educated 
regarding medications and medical conditions and only requires medication pre-fill. The enrollee is making 
progress with physical therapy, 31 visits should be sufficient to meet these goals. 
 
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 the home health services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an abdomen x-ray provided on August 27, 
2023. 
 
You asked the Plan to waive the copayment for an abdomen x-ray. You say that you do not agree with the cost 
sharing. 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 $30 
copayment for each in and out-of-network Medicare-covered x-ray or diagnostic mammogram service. 
 
You have been asked to pay a $30 copayment for an abdomen x-ray. This item/service falls within the each in 
and out-of-network Medicare-covered x-ray or diagnostic mammogram service 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. However, since the allowed amount is 
less than the standard copayment, you only owe $20.39. Therefore, we decided that the Plan does not have to 
waive the copayment for an abdomen x-ray provided on August 27, 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show the need to be seen by a 
rehabilitation physician at least three times a week. The Plan says services may be provided at 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. The medical 
records support 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. It 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve the SNF care. You say that the SNF stay is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for the SNF stay. 
 
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 the 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 did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan. 
 You asked the Plan to pre-approve the drug. You say that rituximab is appropriate for the enrollee's condition. 
The Plan denied your request. The Plan says that the step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug. Our reviewer says that 
Rituxan is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
Plan's required drugs Truxima and Ruxience. Also, there is no indication that the Plan's required drugs would 
likely be less effective or likely have adverse effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 home health skilled nursing visits.  

You asked the Plan to pre-approve 9 home health skilled nursing visits. You say that you would like to request 
reconsideration of the denied claim and that the services requested 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 skilled nursing visits. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
enrollee is noted to be medically stable. They do not require catheterization, G-tube feeding, or administration 
of IV or complex medications. The enrollee has been receiving ongoing wound care for a diabetic wound. It is 
noted that the wound is healed or nearly healed and is not of the complexity to require skilled nursing care. All 
other skilled nursing care goals have been met. 
 
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 skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 9 home health skilled nursing visits.
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 the enrollee requires additional time at the current 
facility due to testing positive for Covid-19. The Plan denied your request. The Plan says the enrollee's 
condition no longer meets the requirements for a SNF admission. 
 
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 skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient admission and stay provided to the enrollee
from January 19, 2023, through January 25, 2023.

You asked the Plan to pay for the inpatient admission and stay. You say that the services should be covered.
The Plan denied your request. The Plan says that these services cannot be covered. Maximus overturned the
Plan's denial based on lack of information. The Plan requested a reopening and stated that this claim cannot be
paid as billed. The Plan is correct in this case. Medicare rules state that outpatient diagnostic services furnished
to a beneficiary more than 3 days preceding the date of the beneficiary's admission to the hospital, by law, are
not part of the payment window and must not be bundled on the inpatient bill with other outpatient services that
were furnished during the span of the 3-day (or 1-day) payment window, even when all of the outpatient
services were furnished during a single, continuous outpatient encounter. The claim submitted by the Plan
indicates the enrollee was admitted to the hospital on January 23, 2023. The claim included outpatient services
provided on January 19, 2023, which is more than 3 days preceding the enrollee's hospital admission date.
Therefore, we decided that the Plan does not have to pay for the inpatient admission and stay provided to the
enrollee from January 19, 2023, through January 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets all criteria for a 
medically appropriate LTACH admission. You say the enrollee should not be denied the opportunity to achieve 
the best quality of life possible. The Plan denied your request. The Plan says the LTACH services are 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with chest pain and septic arthritis in the setting of acute kidney injury requiring dialysis. The record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that he is 
not currently receiving but that would be available at the LTACH facility.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.