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

We decided that the Plan does not have to pay for an eye exam refraction (92015) performed on September 21, 
2020. 
 
You asked the Plan to pay for an eye exam refraction. You say that since the refraction was needed to see if 
surgery was necessary it should be included in the benefit as part of that surgery. The Plan denied your request. 
The Plan says rules for payment have not been met. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. The Plan covers routine vision services when 
received from a Plan-specified vision-care provider. 
 
We looked at the file and the Plan's rules. In this case, the record shows that an eye exam refraction was 
performed not as part of a routine eye exam but as part of a medical diagnostic exam. The Plan only covers eye 
refractions as part of a routine eye exam. Based on this information, we decided that the Plan's rules for 
coverage of an eye exam refraction have not been met. Therefore, we decided that the Plan does not have to 
pay for an eye exam refraction (92015) performed on September 21, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from May 19, 2020 to July 
17, 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 claims were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with the 
proper HHRG code. 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with the appropriate 
HHRG code. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
May 19, 2020 to July 17, 2020.
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 an LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of an LTACH admission. 
 
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 that the patient was admitted to the current acute care hospital with hypoxic 
respiratory failure due to COVID-19 pneumonia and diarrhea as well as acute kidney injury. She was treated 
with high-flow oxygen, remdesivir, steroids, fluids, antibiotics, and Lovenox. Her diarrhea improved, kidney 
function stabilized, and oxygen requirements are lowering based on recent notes. The patient appears to be 
improving sufficiently to need only short-term additional acute care services which can safely be received at 
the current facility. The patient does not require services at the LTACH that are already available at the current 
facility. There are no services at the LTACH that the patient requires that are not already available and covered 
at the current facility. Transfer may be considered when treatment has been completed. Therefore, this request 
for LTACH services will be considered not medically 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 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay forphysician services provided to the enrollee from May 1, 2020, to July 3, 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 forphysician services provided to the enrollee from May 1, 2020, to July 3, 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 toopen the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the closed treatment of an interphalangeal joint dislocation (23770) 
provided on July 9, 2020. 
 
You asked the Plan to pay for the closed treatment of an interphalangeal joint dislocation. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not 
support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 26770 is closed treatment of interphalangeal joint dislocation, 
single, with manipulation; without anesthesia.  
 
We asked our coder 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 closed treatment of an interphalangeal joint dislocation. Our reviewer says 
that CPT code 26770 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical 
records provided do not include documentation to validated that a closed treatment of interphalangeal joint dislocation, 
single, with manipulation; without anesthesia was performed on July 9, 2020, therefore this service cannot be verified.  
The medical records indicate this service was performed on July 10, 2020. 
 
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 closed treatment of an interphalangeal joint dislocation have not been met. Therefore, we decided that 
the Plan does not have to pay for the closed treatment of an interphalangeal joint dislocation (23770) provided on July 9, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the train-of-four (TOF) testing provided during 
intraoperative monitoring on May 14, 2020. 
 
You asked the Plan to pay for the TOF testing. You say that this should be paid in full. The Plan denied your 
request. The Plan says all codes were approved for payment aside from code 95999. 
 
The Plan must follow Medicare rules. Medicare rules say that it is not appropriate to separately report 
procedures which are integral to other procedures billed.  
 
TOF testing is an integral part of intraoperative neuromonitoring. As such, separately report this portion of the 
service is not appropriate. Therefore, we decided that the Plan does not have to pay for the train-of-four (TOF) 
testing provided during intraoperative monitoring on May 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0433, A0425) 
received on August 5, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not be 
responsible for this bill. The Plan denied your request. The Plan says you were charged this cost sharing 
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 $225 
copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $225 for these services. 
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 ambulance services (A0433, A0425) received on August 
5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary implant/abutment supported removable denture 
for edentulous arch and mandibular implant/abutment supported removable denture for edentulous arch, or pay 
more for the complete maxillary denture and complete mandibular denture provided from October 11, 2019, to 
November 19, 2019. 
 
You asked the Plan to pay for the maxillary implant/abutment supported removable denture and mandibular 
implant/abutment supported removable denture and pay more for the complete maxillary denture and complete 
mandibular denture. You say that you were given permission to receive these services, and your dental plan had 
$2,000 for you to use. You also say that you believe these services were unfairly denied. The Plan denied your 
request. The Plan says the maxillary implant/abutment supported removable denture for edentulous arch and 
mandibular implant/abutment supported removable denture for edentulous arch are not covered benefits. The 
Plan also says that the complete dentures were pre-authorized in 2019, billed on November 19, 2019, and 
covered at 75%. 
 
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 maxillary implant/abutment 
supported removable denture for edentulous arch and mandibular implant/abutment supported removable 
denture for edentulous arch are not among those covered under this benefit. The Plan contract also says that 
you are responsible for a 25% coinsurance for supplemental prosthodontic dental benefits.  
 
Therefore, we decided that the Plan does not have to pay for the maxillary implant/abutment supported 
removable denture for edentulous arch and mandibular implant/abutment supported removable denture for 
edentulous arch, or pay more for the complete maxillary denture and complete mandibular denture provided 
from October 11, 2019, to November 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four gingival irrigations and full mouth debridement 
provided on February 13, 2020. 
 
You asked the Plan to pay for the gingival irrigations and full mouth debridement. You say that this was just a 
follow up visit, and the enrollee should not have to pay for anything. The Plan denied your request. The Plan 
says these services are not covered. 
 
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 four 
gingival irrigations and full mouth debridement provided on February 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a lipid panel (80061) performed on July 14, 
2020. 
 
You asked the Plan to waive the copayment for the lipid panel. You say that blood tests do not have a copay. 
The Plan denied your request. The Plan says there is a $5 copayment for lab services. 
 
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 $5 
copayment for laboratory tests.  
 
You have been asked to pay a $5 copayment for a lipid panel. A lipid panel is a laboratory test 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 the lipid panel (80061) performed on July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT (D0364) provided on October 6, 2020. 
 
You asked the Plan to pay for the cone beam CT. You say that you did not realize the provider was out of 
network. You say that they should not have even seen you or taken your money if that was the case. You say 
that you did not know the services would not be covered. You also say that you are on a limited income. The 
Plan denied your request. The Plan says cone beam CT is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 cone 
beam CT (D0364) provided on October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on 
September 24, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you received 1 
cleaning during the time you had the enhanced dental insurance, and you thought you were eligible for a 
second cleaning. The Plan denied your request. The Plan says these services are payable once per calendar 
year. 
 
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, oral exams and prophylaxes and are 
each payable once per calendar year. The record shows that you received an oral exam and cleaning on June 
15, 2020 and your oral exams and prophylaxis benefits had been exhausted. You changed plans in February 
2020. The new dental coverage only covers one annual exam and cleaning, which you received in June. 
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis 
provided on September 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive procedure (D9999) provided on May 5, 2020. 
 
You asked the Plan to pay for the adjunctive procedure. You say that you would like the out-of-pocket cost 
reimbursed to you. The Plan denied your request. The Plan says this service is not a covered benefit under your 
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 
adjunctive procedure (D9999) provided on May 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies provided from July 28, 2020 to August 
3, 2020. 
 
You asked the Plan to pay for the infusion supplies (A4221, A4222). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the documentation submitted did not include an itemized 
shipping/billing invoice or proof of delivery indicating the specific supplies dispensed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket 
does not have the tracking number on it and the Proof of Delivery does not have a description of the items 
delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the infusion supplies provided from July 
28, 2020 to August 3, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you are 
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, you received oral medications, had stable vital signs, and your lungs 
were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a 
minimal to 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) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that intravenous iron will assist in higher hemoglobin 
levels. The Plan denied your request. The Plan says your iron levels are not low. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Injectafer. Our physician reviewer 
found that the requested use of Injectafer is not FDA-approved for your diagnosis. Its use is not supported by 
one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The 
documentation does not support that the requested drug is safe and effective and otherwise reasonable and 
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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 5, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because the 
services rendered were medically necessary. The Plan denied your request. The Plan says services rendered by 
nonparticipating providers require prior authorization as outlined in the enrollees EOC. 
 
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 medical services provided on February 5, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires provided to the enrollee on September 18, 
2020. 
 
You asked the Plan to pay for the lead wires. You say that this should be covered by the Plan. The Plan denied 
your request. The Plan says that records supporting the medical necessity of the additional lead wires were not 
submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The file indicates the enrollee has previously received lead wires within twelve months. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the lead wires provided to the enrollee on September 18, 
2020.