Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated breast prosthesis (L8001, L8035). 
 
You asked the Plan to pre-approve the prosthesis. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that a custom fabricated breast prosthesis is not covered. 
 
Medicare does not find the additional features in a custom fabricated breast prosthesis to be medically 
reasonable or necessary. Based on this information, we decided that Medicare rules for coverage of the 
prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom 
fabricated breast prosthesis (L8001, L8035).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay for the x-ray (70145) provided to the enrollee on July 14, 2020.
You asked the Plan to pay for x-ray services provided to the enrollee. 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 stated this claim denied because this service was paid previously to another provider of the same group for the same enrollee. The Plan included the claim images for review. The Plan also notes both providers work for the same radiology group. In addition, the Plan stats the each edit table contains edits which are pairs of HCPCS/CPT codes that in general should not be reported together. Each edit has a column one and column two HCPCS/CPT code. If a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. However, if it is clinically appropriate an NCCI-associated modifier can be used.
The Plan is correct in this case. 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 services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as an appropriately billed service. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for the x-ray (70145) provided to the enrollee on July 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the neck for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical information received does not show that the requirements have been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found a review of the records 
shows no history of trauma. The cervical spine series of 12/4/20 revealed asymmetry of the C1-2 on the open 
mouth view but the finding as described as possibly positional and the quality of the view was described as 
poor. While the investigation of an abnormality at C1-2 is indicated the first step would have been to repeat the 
open mouth view with optimal technique. If such a view confirms a finding worthy of investigation and to rule 
out rotary subluxation cross sectional imaging without PT would be indicated to rule out instability at that 
level. Due to the absence of trauma and the suboptimal nature of the x-ray view in question the medical 
necessity of MRI of the cervical spine has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the neck for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for physician office visits provided to the enrollee from July 20, 2020 to August 10, 2020.
You asked the Plan to pay these services. You say that you are eligible to accept Medicare payment as an out of network provider and these services should be covered by the Plan. The Plan denied your request. The Plan says that you are excluded or debarred from participation in State and Federal healthcare programs. Maximus upheld the Plans denial. After additional review of several cases from your office, we reopened the appeal.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services were met. The Plan did not provide documentation to show that you are excluded from receiving Medicare reimbursement. Maximus performed a search of the List of Excluded Individuals and/or Entities from the Office of Inspector General and did not find that you were on this list. Without specific documentation from the Plan showing that you were excluded to receive Medicare reimbursement at the time the services were provided, the denial cannot be substantiated. Therefore, we decided that the Plan has to pay for physician office visits provided to the enrollee from July 20, 2020 to August 10, 2020.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay forphysician services provided to the enrollee on July 6, 2020.You asked the Plan to pay these services. You say that you are eligible to accept Medicare payment as an out of network provider and these services should be covered by the Plan. The Plan denied your request. The Plan says that you are excluded or debarred from participation in State and Federalhealthcare programs. Maximus upheld the Plans denial. After additional review of several cases from your office, we reopened the appeal. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services were met. The Plan did not provide documentation to show that you are excluded from receiving Medicare reimbursement. Maximus performed a search of the List of Excluded Individuals and/or Entities from the Office of Inspector General and did not find that you were on this list. Without specific documentation from the Plan showing that you were excluded to receive Medicare reimbursement at the time the services were provided, the denial cannot be substantiated. Therefore, we decided that the Plan has to pay forphysician services provided to the enrollee on July 6, 2020.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 toshow 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not 
require skilled therapies that can only be provided in a skilled nursing facility. 
 
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 SNF services. Our physician reviewer 
found that from a nursing perspective, you receive oral medications, and have stable vital signs. There are no 
identifiable skilled nursing service needs. Regarding rehab services, you are at a moderate assist level with 
functional mobility. You require varying assist with activities of daily living. Although there are identifiable 
skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do 
not meet 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assisted living visit provided on June 9, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the assisted living visit. You say that the providers rely on the facility to obtain 
any necessary authorizations when your providers are asked to see patients at the facility for medical treatment. 
The Plan denied your request. The Plan says the service was rendered by a non-network provider. The Plan 
also says that the enrollee's primary care physician did not refer the enrollee for the service. 
 
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 
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 assisted living visit provided on June 9, 2020 
by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SSM Day Institute outpatient rehabilitation program. 
 
You asked the Plan to pre-approve SSM Day Institute outpatient rehabilitation program. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 SSM Day Institute outpatient 
rehabilitation program. Our reviewer says that skilled services are not necessary to restore or maintain function 
or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had 
extensive physical therapy, occupational therapy, and physical therapy and the enrollee's current functional 
level does not require the ongoing professional skills of a physical, occupational, or speech therapy at a 
outpatient SSM Day Institute outpatient rehabilitation program. The enrollee's current functional level and 
needs do not require physical therapy, occupational therapy, and physical therapy in an outpatient specialized 
intensive day institute program level as this would exceed his medical need. Family and enrollee education has 
been provided. The enrollee's functional level is high and the enrollee's needs now of supervision do not require 
skilled therapists in an outpatient specialized intensive day institute program. Therefore, the enrollee does not 
meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SSM Day Institute outpatient rehabilitation program have not been met. 
Therefore, we decided that the Plan does not have to pre-approve SSM Day Institute outpatient rehabilitation 
program.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPAP accessories (HCPCS A9279) provided to the enrollee 
on September 24, 2020. 
 
You asked the Plan to pay for the accessories. You say that this should be paid for. The Plan denied your 
request. The Plan says the provider has been informed that this service was billed incorrectly. 
 
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 HCPCS code A9279 is "Monitoring feature/device, stand-
alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified." 
 
We find that HCPCS code A9279 is not supported in the medical record. Specifically, Medicare statutorily 
denies the use of this code. Based on this information, we decided that Medicare rules for coverage of the 
accessories have not been met. Therefore, we decided that the Plan does not have to pay for CPAP accessories 
(HCPCS A9279) provided to the enrollee on September 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant /abutment supported removable denture for 
edentulous arch (D6111) provided on August 13, 2020. 
 
You asked the Plan to pay for the implant /abutment supported removable denture. You say that you would like 
this claim to be reconsidered for payment. The Plan denied your request. The Plan says this service is not a 
covered benefit under the enrollee's dental plan. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
implant /abutment supported removable denture for edentulous arch (D6111) provided on August 13, 2020.
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 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 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 this 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal exam (D0180), the complete series x-ray 
(D0210), prophylaxis (D1110), and the extraction (D7140) provided from August 19, 2020, to August 24, 
2020. 
 
You asked the Plan to pay for the dental services. You say that you need heart surgery. You say that you were 
advised you needed these dental services done before you could have your heart surgery. You also say that the 
services should be covered because the surgery changed your life for the better. The Plan denied your request. 
The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be 
made for services that you receive from a provider who has opted out of Medicare. 
 
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 the 
periodontal exam (D0180), the complete series x-ray (D0210), prophylaxis (D1110), and the extraction 
(D7140) provided from August 19, 2020, to August 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 30, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on September 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (36415, 80061, 82306, 80053) 
provided by an out of network (OON) provider. 
 
You asked the Plan to pay for OON laboratory services. You say that these services were required by the 
enrollee's physician. The Plan denied your request. The Plan says these services were not authorized. 
 
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 laboratory services (36415, 80061, 82306, 
80053) provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the computed tomography (CT) scan of the 
abdomen and pelvis (74178), the computed tomography (CT) scan of the thorax (72170), and the low osmolar 
contrast material (Q9967) provided on August 14, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $100 
copayment for each in-network Medicare-covered radiological diagnostic service, not including x-rays, 
performed in a physician?s office or at a free-standing facility (such as a radiology center or medical clinic). 
Additionally, you pay a 20% coinsurance for each in-network Medicare-covered medical supply. 
 
You have been asked to pay $201.80 ($100 copayment x 2) for the Medicare-covered radiological diagnostic 
services provided. Additionally, you pay a $1.80 (Plan allowed amount of $9 x 20% coinsurance) for the 
Medicare-covered medical supply provided. 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 adjust the copayment for the 
computed tomography (CT) scan of the abdomen and pelvis (74178), the computed tomography (CT) scan of 
the thorax (72170), and the low osmolar contrast material (Q9967) provided on August 14, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs skilled services as he 
continues to make neurological improvements. The Plan denied your request. The Plan says the enrollee is 
receiving the appropriate care in the inpatient rehab facility. 
 
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 SNF services. Our physician reviewer 
found that from a nursing perspective, the enrollee received enteral and oral nutrition, had stable vital signs, 
and his lungs were clear. Regarding rehab services, the enrollee was at a contact guard to moderate assist level 
with bed mobility. He required varying assist with activities of daily living. Although there are identifiable 
skilled nursing and therapy service needs, the enrollee does not require skilled services on a daily basis. The 
enrollee does not meet 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.