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

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the records provided support the need for SNF care.The Plan denied your request. The Plan says the criteria for coverage have not been met. The Plan says that the enrollee does not have intense or complex care needs requiring ongoing recovery in the SNF.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and tolerated dialysis. The enrollee had uncomplicated wound care to her left inner thigh and her lungs were clear. The enrollee received physical therapy and occupational therapy in the SNF. The enrollee required extensive assistance with transfers and toileting. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for 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 the SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 8, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you chipped your tooth. You say that in order to 
have a dentist treat you, you had to have an evaluation done. You also say that this was not a routine visit, but 
an emergency. The Plan denied your request. The Plan says one oral evaluation every six months. The Plan 
also says that the frequency limit has been exceeded. 
 
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 frequency limit of one oral 
evaluation every six months has been exceeded. The record shows that the Plan paid for a periodic oral 
evaluation that you received on June 1, 2020, less than six months prior. Therefore, we decided that the Plan 
does not have to pay for the limited oral evaluation (D0140) provided on October 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthroplasty services (CPT 27130) provided to the enrollee 
on July 23, 2020 and July 24, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says with a device-dependent procedure, there must be an associated qualifying device reported on 
the same claim for the same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 27130 is "Arthroplasty, acetabular and proximal femoral 
prosthetic replacement (total hip arthroplasty), with or without autograft or allograft." 
 
We asked our coding 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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found per the 
Medicare Claims Processing Manual Chapter 4, 61.2 - Edits for Claims on Which Specified Procedures are to 
be Reported With Device Codes and For Which Specific Devices are to be Reported With Procedure Codes; 
"The OCE will return to the provider any claim that reports a HCPCS code for a device-intensive procedure 
that does not also report at least one device HCPCS code required for that procedure". 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for arthroplasty services (CPT 27130) provided to the enrollee on July 23, 2020 and July 24, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound examination provided on 
August 24, 2020. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you were previously charged less for 
services. The Plan denied your request. The Plan says the copayment amount you are being charged is correct. 
 
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 $125 
copayment for ultrasound.  
 
You have been asked to pay $125 copayment for ultrasound. Ultrasound falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies 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 an ultrasound examination provided on August 24, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stem cell injection services. 
 
You asked the Plan to pre-approve the stem cell injection services. You say that you are in extreme pain and 
your condition is getting worse. The Plan denied your request. The Plan says the requested treatment is not 
considered medically reasonable and necessary. 
 
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 the stem cell injection services. Our 
reviewer says that the requested stem cell injection services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has right shoulder pain with adhesive 
capsulitis. The enrollee takes Diclofenac topical for pain and has had a steroid intra-articular injection, which 
did not help. The requested stem cell injection services are considered experimental and investigational 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 stem cell injection services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve stem cell injection services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessories. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the 
enrollee's upper limb strength and function are adequate for the enrollee to control the approved power options 
using their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications. 
 
The file shows that calf rests were requested. We looked at the file and the rules. Leg rests are included in the 
power wheelchairs basic equipment package. There is no separate billing/payment if calf pads are provided. 
Coding for replacement calf pads are not used at the time of initial use. Based on this information, the Medicare 
rules for coverage have not been met.  
 
The file shows that a center mount power elevating leg rest was requested. We looked at the file and the rules. 
The records do not indicate that the enrollee has a covered indication in which an elevating leg rest would be 
covered. Based on this information, we decided that the Medicare rules for coverage have not been met.  
 
The file shows that an electronic connection between 2 or more power options was requested. 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 requested items. Our physician reviewer found that 
the enrollee has upper extremity strength on the left of 4 out of 5, with normal range of motion; and 2 out of 5 
on the right. The right upper limb contracture is dependent on positioning. The enrollee has sufficient strength 
in the left upper extremity to operate any power options through their own individual switches. Therefore, the 
electronic connection is not medically reasonable or necessary 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 requested items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve wheelchair accessories.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to pre-approve deep pressure compression vest for the enrollee.
You asked the Plan to pre-approve deep pressure compression vest or weighted vest for anxiety. You say that
this item is medically necessary for the enrollee. The Plan denied your request. The Plan says this item does not
serve a direct medical purpose and is not covered by Medicare. Maximus overturned the Plans denial stating
there is the possibility that this vest would be beneficial. The Plan requested a reopen and stated that while
there is no disagreement this equipment may be "beneficial", it is not covered by Medicare.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that for equipment to be
covered, it must primarily serve a medical purpose. This vest does not have an assigned Medicare billing code.
This vest can be purchased in commercial retail without a prescription from a medical professional. While this
item may be beneficial for the enrollee, it is not covered by Medicare under any circumstance. Therefore, we
decided that the Plan does not have to pre-approve deep pressure compression vest for the enrollee
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 22 home health visits for the enrollee.
You asked the Plan to pre-approve 22 home health visits. You say that home health services are medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus made
the original decision about 5 visits only. The Plan requested a reopen and provided documentation of all visits
reviewed.
The Plan is correct in this case. 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 22 home health visits. Our reviewer says that Medicare coverage criteria are not met.
Our physician reviewer found the documentation does not support that the enrollee in this case requires skilled
nursing services or skilled therapy services in the home. The enrollee does not need home health care to
improve her condition or to prevent deterioration. There is no documentation in the medical records that
supports a need for home skilled nursing visits. The medical records also do not confirm that the enrollee is
homebound. The records do indicate the enrollee is independent with ambulation. Medicare coverage criteria
for home health care are not 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 22 home health visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve 22 home health visits for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to waivethe cost share charged for an echocardiogram ($25) and PartB drug injection (20% coinsurance) provided on June 5, 2020.You asked the Plan to waivethis cost share. You say that you do not believe this cost share is correct.The Plan denied your request. The Plan says this cost share was charged based on the services provided and the Plan contract agreement. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct contract language.The Plan is correct in this case. 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 cost share for imaging services and Medicare Part B drugs. The echocardiogram is an imaging service and requires a $25 copayment. The injection provided requires a 20% coinsurance as it falls in the category of a Medicare Part B drug. 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 waiveor reduce the cost share charged for an echocardiogram ($25) and Part B drug injection (20% coinsurance) provided on June 5, 2020
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pre-approvea CT scan of the abdomen and pelvis; with contrast material(s) for the enrollee.You asked the Plan to pre-approvea CT scan of the abdomen and pelvis. You say that the requested imaging is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.Our Medical Director looked at the case file and the reopen request. At issue is coverage for a CT scan of the abdomen and pelvis with contrast. The Maximus Physician Reviewer determined that the requested CT scan was medically reasonable and necessary every 6to 12 months for 5 years. However, the Plan submitted additional medical records with the reopen that were not available during the first review. These medical records show the enrollee has a history of "pT3,pN1,MX, stage 3B"moderately differentiated adenocarcinoma of the right colon. The enrollee underwent right total colectomy on January 5, 2017.Our Medical Director says that the Plan is correct in this case. The additional medical records submitted include a Radiology Report for a CT scan of the chest, abdomen and pelvis performed on June 23, 2020. With a CT scan recommended every 6 to 12 months for 5 years, a repeat CT scan would not have been medically reasonable and necessary until December 23, 2020. The appeal was three months prior to that in October. Therefore, Medicare coverage criteria were not 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 a CT scan of the abdomen and pelvis have not been met.Therefore, we decided that the Plan does not have to pre-approvecomputed tomography (CT) scan of the abdomen and pelvis; with contrast material(s) (CPT Code 74177) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0652) and segmental 
pneumatic appliance/sleeve (E0667 x2) . 
 
You asked the Plan to pay for a pneumatic compression device and sleeve. You say that the records provided 
should support the necessity of the service in dispute. The Plan denied your request. The Plan says the enrollee 
does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four week trial of a 
basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device 
(E0652) and segmental pneumatic appliance/sleeve (E0667 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on May 8, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that it is the surgeon's responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 has network providers 
available who can provide 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 specialist services provided on May 8, 2020 by an 
out of network (OON) provider.
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 clinical information provided supports the need 
for care in an IRF. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
coverage of IRF 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 above. 
 
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 enrollee 
was admitted for weakness and was treated for sepsis associated with acute prostatitis. The enrollee's medical 
conditions are stable. There are no medical needs requiring inpatient admission. 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 documents a need for 
physical and occupational therapy, it does not document a need for an intensive 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics, insert, removable, molded to patient 
model, longitudinal/ metatarsal support, each (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that you are appealing the decision to deny the 
orthotics. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics, insert, removable, 
molded to patient model, longitudinal/ metatarsal support, each (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the digital hearing aids (V5261 x 2) 
rendered by the out of network (OON) provider on July 21, 2020. 
 
You asked the Plan to issue reimbursement 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 the hearing aids were rendered by 
an out of network provider, without prior authorization. 
 
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 issue reimbursement for care from out-of-network providers only in cases 
involving emergencies, out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no 
exception that would require the Plan to issue reimbursement for these items. Therefore, we decided that the 
Plan does not have to issue reimbursement for the digital hearing aids (V5261 x 2) rendered by the out of 
network (OON) provider on July 21, 2020.