Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dentures (D5213 and D5214). 
 
You asked the Plan to pre-approve the dentures. You say that you cannot afford to pay this cost. The Plan 
denied your request. The Plan says this exceeds the benefit allowance. 
 
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. The Plan covers dentures once 
every five years.  
 
Dentures were last received on November 7, 2016. Based on this information, we decided that the Plan's rules 
for coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pre-
approve dentures (D5213 and D5214).
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on June 11, 2019.
You asked the Plan to pay for this lab service. You say that this testing should be covered by the Plan. The Plan
denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans
denial stating that code G0481 was supported by the medical records provided. The Plan requested a reopen
and stated that this was not a medical necessity issue but an administrative issue due to an error in billing on the
claim. The Plan says that this service does not meet the criteria for the category under which it was billed. After
clinical review of the medical records, the service was determined to be coded incorrectly. This is a billing
error on the part of the provider and the service is not reimbursable. The Plan states that the records do not
contain documentation of definitive laboratory results for 8-14 drug classes, including metabolites to support
the coding criteria for G0481. The Plan states that the Local Coverage Determination (LCD): Lab: Controlled
Substance Monitoring and Drugs of Abuse Testing (L36668) explains that Urine drug testing (UDT) provides
objective information to assist clinicians in identifying the presence or absence of drugs or drug classes in the
body and making treatment decisions. Therefore, the claim was not coded correctly by the provider.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, the claim submitted was not billed under
the appropriate category for the services billed. The Plan states the issue was not the medical necessity of the
testing but the inappropriate billing of the claim. Review of the case file and the reopen with the additional
information provided demonstrates the Plan is correct in this case. Therefore, we decided that the Plan does not
have to pay for drug testing provided to the enrollee on June 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vraylar 1.5mg capsules. 
 
You asked the Plan to pre-approve the Vraylar capsules. You say that you have failed other medications and 
feel that this should be approved. The Plan denied your request. The Plan says this oral drug cannot be covered 
by Medicare Part B. Part D coverage must be requested. 
 
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 pre-approve Vraylar 1.5mg capsules.  
 
Benefits for the Vraylar capsules 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on September 23, 
2020. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you have only had 2 fillings in a year and do 
not understand how the limit has been exceeded. The Plan denied your request. The Plan says the frequency 
limit for this service 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, bitewings (D0274) are limited to one 
procedure per plan year. The record shows that you received bitewings (D0274) on March 4, 2020, and your 
bitewings (D0274) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the 
bitewing x-rays (D0274) provided on September 23, 2020.  
 
Your complaint about your unhappiness with the Plan is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Omnipod Dash insulin pump. 
 
You asked the Plan to pre-approve the insulin pump. You say that the enrollee has tried oral and injectable 
alternatives and has failed to get better glycemic control. You say that the enrollee needs the ability to have 
multiple basal rates to avoid hypoglycemia and to get to target blood glucose levels. You also say that the 
Omnipod would improve the enrollee's overall glycemic control and prevent further diabetic complications in  
the future. The Plan denied your request. The Plan says drugs covered under a Medicare Part D prescription 
drug plan cannot be covered under Medicare Part B. 
 
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 pre-approve an Omnipod Dash insulin 
pump.  
 
Benefits for the insulin pump 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies (S1015 and S8301) provided on August 6, 
2020. 
 
You asked the Plan to pay for medical supplies. You say that these items were provided at the request of the 
surgeon. The Plan denied your request. The Plan says these items were not billed with valid codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes S1015 and S8301 are not supported in the medical record. Specifically, these codes 
have a status indicator of ?I.? Medicare uses another code for reporting of, and payment for these services. 
Based on this information, we decided that Medicare rules for coverage of medical supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for medical supplies (S1015 and S8301) provided on 
August 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from 
May 23, 2020 to May 28, 2020. 
 
You asked the Plan to pay for this service. We note the Plan paid for SNF services from May 28, 2020 to June 
21, 2020. You say that these services should be covered by the Plan. The Plan denied your request. The Plan 
says while a portion of these services were covered, Medicare coverage criteria were not met on the dates in 
question. 
 
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 
pay for this service. Our physician reviewer found at issue is coverage for SNF services from May 23, 2020, to 
May 28, 2020. The Plan has agreed to coverage of SNF care from May 28, 2020 to June 21, 2020. The enrollee 
was an 85-year-old woman with a history of COPD, diabetes, hypertension, pneumonia, sepsis, generalized 
muscle weakness, gait and mobility abnormalities, and dysphagia, who was a resident of Hughes Health and 
Rehabilitation. It is documented that care was started on May 11, 2020 ended on May 22, 2020.  
 
The enrollee was discharged to the same SNF as LTC independent at rollator level.  No required skilled nursing 
services are identified for the dates in question. The documentation does not support that the enrollee required 
skilled therapy services on a daily basis in an inpatient basis in an SNF for the dates in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service. We note the Plan paid for SNF services from May 28, 2020 to June 
21, 2020 have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing 
facility services provided to the enrollee from May 23, 2020 to May 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone density measurement of the core or central skeleton 
(77080) provided by an out of network (OON) provider. 
 
You asked the Plan to pay for the bone density measurement of the core or central skeleton. You say that you 
would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. 
 
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 bone density measurement of the core or 
central skeleton (77080) provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy procedure provided on May 13, 2020 billed 
with code 45390-59-76. 
 
You asked the Plan to pay for the colonoscopy service as billed. You say that this service was provided 
multiple times on the date of service so all line items should be paid. The Plan denied your request. The Plan 
says the records do not support this code. 
 
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 45390 is Colonoscopy, flexible; with endoscopic mucosal 
resection. 
 
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 colonoscopy service as billed. Our 
reviewer says that the records do not support the billed code. Our coding reviewer found the medical records 
provided to not include sufficient documentation to validate that another colonoscopy, flexible; wit endoscopic 
resection procedure or service was repeated subsequent to the original procedure or service. Therefore, 
additional unit of 45390 billed to the health plan with a 59 modifier and a 76 modifier cannot be verified.  
 
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 colonoscopy service as billed have not been met. Therefore, we decided that 
the Plan does not have to pay for the colonoscopy procedure provided on May 13, 2020 billed with code 
45390-59-76.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 18, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is 
important to know which providers are part of our network providers to get your medical care and services. The 
only exceptions are emergencies, urgently needed services when the network is not available, out-of-area 
dialysis services, and cases in which the plan authorizes use of out-of-network providers. 
 
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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on May 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on January 6, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the 
enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis 
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, 
which requires prior authorization from the Plan. 
 
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 did not pre-approve the 
psychotherapy services. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on January 6, 
2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on April 30, 2020. You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan states thatthis claim denied because this service was previously paid under another claim. The Plan provided information to show they previously paid this service under a different claim number to a provider in the same practice group. Therefore, the second claim cannot be paid as billed. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group,only one service may be reported unless theevaluation and management services are for unrelated problems. Based on the medical records provided, this claim cannot be paid as billed due to the physician group relationship between the two providers. Medicare billing criteria were not met. Therefore,we decided that the Plan does not have to pay forphysician services provided to the enrollee on April 30, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan does not have to pay for emergency room services billed to the enrollee for date of
service April 20, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional claim information. The Plan says that this claim denied because
they had already paid for this service under another claim. The Plan states that this service was paid to another
provider in the same practice group. The Plan states that the NPI website shows both providers practice as
Emergency Medicine Specialists. The Plan included the claims for each provider. Both providers belong to the
same physician group.
The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same
day to the same patient by the same physician or more than one physician in the same specialty in the same
group, only one service may be reported unless the evaluation and management services are for unrelated
problems. Based on the medical records provided, this claim cannot be paid as billed due to the physician
group relationship between the two providers. Medicare billing criteria were not met. Therefore, we decided
that the Plan does not have to pay for emergency room services billed to the enrollee for date of service April
20, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 18, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. We overturned the Plans decision. The
Plan requested a reopen and provided additional claim information. The Plan says that it has been determined
that this claim denied because this service was previously paid to another provider in the same practicing
group. The Plan states that modifier 26 is used to indicate the professional component of the service being
billed was "interpretation only," and it is most commonly submitted with diagnostic tests, including
radiological procedures. In this case the provider should have billed modifier 59, XE, or XP to bypass the edit.
The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same
day to the same patient by the same physician or more than one physician in the same specialty in the same
group, only one service may be reported unless the evaluation and management services are for unrelated
problems. Based on the medical records provided, this claim cannot be paid as billed due to the physician
group relationship between the two providers unless the claim is billed with a modifier 59. Medicare billing
criteria were not met. Therefore, we decided that the Plan does not have to pay for physician services provided
to the enrollee on May 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Naltrexone. 
 
You asked the Plan to pre-approve Naltrexone. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 pre-approve Naltrexone.  
 
Benefits for Naltrexone 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: 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 pre-approve Ondansetron.  
 
Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.