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

We decided that the Plan does not have to pre-approve a myoelectric prosthetic (L8702)for the enrollee.
You asked the Plan to pre-approve a myoelectric prosthetic (L8702). You say that this prosthetic 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 Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. Our Medical Director says that at issue is coverage for a custom fabricated powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories. The Maximus Physician Reviewer determined that the requested item is considered medically reasonable and necessary in this case. Our physician reviewer found current evidence supports the benefit of myoelectric prosthetic devices in the setting of permanent paresis of extremities compared to first line treatment options. This patient has failed first line treatments and would clearly benefit from the MyoPro device to help them with daily activities, requiring less assistance. The Plan requested a reopen and stated the records do not establish a medical necessity versus a convenience. The medical records show the enrollee is a 64-year-old man with right hemiparesis following a stroke in 2018. The enrollee has failed traditional therapies for the hemiparesis, including bracing, e-stim, and Botox. However, our Medical Director says the plan is correct in this case. At this time the requested myoelectric orthosis is not proven to be more beneficial for treatment of a patient's medical condition of hemiparesis following stroke as compared to available standard therapy. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member in this case. Therefore, Medicare coverage criteria 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 a myoelectric prosthetic (L8702) have not been met. Therefore, we decided that the Plan does not have to pre-approve a myoelectric prosthetic (L8702)for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to pre-approve an Inogen portable oxygen system.
You asked the Plan to pre-approve an Inogen portable oxygen system. You say that a portable oxygen system is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met because there is no indication that you cannot use liquid oxygen tanks inside the home. Maximus overturned the Plans denial stating you meet the criteria for the requested oxygen system. The Plan requested a reopen and stated that Maximus did not follow the required Medicare coverage criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the documentation must show that the patient is mobile in the home and also requires portable oxygen in the home. The medical records show that you have oxygen equipment in the home and that you state you cannot use portable tanks with your walker or when you leave the home for chemotherapy. However, the medical records provided by your physician are inconsistent. A letter from your physician indicates an Inogen system is medically necessary for home use and for use at long appointments because the liquid tanks are heavy. Your physician also indicated in a pier to pier with the Plan that liquid oxygen tanks are not a problem in the home. The Maximus physician reviewer indicated that the requested equipment would be beneficial to the enrollee and notes the use outside of the home. Medicare does not cover portable oxygen equipment for use outside of the home, even for chemotherapy. Medicare only covers portable oxygen equipment inside the home for a specific medical condition as opposed to convenience for ambulating in the home. Due to discrepancies in the medical records, a second review shows this equipment was provided more for convenience inside and outside of the home, which is not covered by Medicare, as stated above. Therefore, we decided that the Plan does not have to pre-approve an Inogen portable oxygen system.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan does not have to pay additional reimbursement for dental services provided on March 16, 2020.
You asked the Plan to pay additional reimbursement for these dental services. You say that the Plan should pay an additional $185 towards these services as they should be covered under your medical services. The Plan denied your request. The Plan says that the services in this case are dental in nature. The Plan says that there is a $1,000 dental allowance. The Plan says that the $1,000 allowance has been exhausted in processing this claim. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not correctly interpret the dental benefit.
The Plan is correct in this case. Medicare does not cover dental services. 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 up to $1000 for dental benefits, which the Plan has demonstrated has been paid. Your provider submitted a claim for codes that are classified as dental codes and cannot be "converted" to medical service codes by the Plan. The Plan is required to pay the claim based on the codes submitted by your provider. Therefore, we decided that the Plan does not have to pay additional reimbursement for the surgical extractions (D7210 x 11), removal of tooth roots (D7250 x 14), and nitrous oxide (D9230) provided on March 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 COVID-19 pneumonia. 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 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 cellulitis of right leg and acute on chronic congestive heart failure. 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 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this level of care is not medically necessary at this time. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
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 skilled nursing facility 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the simple 
extraction (D7140), the surgical extraction (D7210), and the complete series x-ray (D0210) provided on July 
13, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were told where to go by a plan 
representative. You say that now you received a letter saying the services were done out of network. The Plan 
denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental 
services that you receive out of network 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, dental services that you receive out of 
network are not among those covered under this benefit. The record shows that you called the Plan to verify if a 
dentist was in network, however, that dentist is not the dentist that provided the services in this case. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the simple 
extraction (D7140), the surgical extraction (D7210), and the complete series x-ray (D0210) provided on July 
13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional LogistiCare mileage for an additional two 
miles for a total of 52 miles. 
 
You asked the Plan to pre-approve additional LogistiCare mileage. You say that you require additional routine 
transportation miles to attend medical appointments. The Plan denied your request. The Plan says this service is 
a covered benefit but your request exceeds your mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, the 51st mile 
and beyond is not a covered benefit. Your 2021 EOC states each one-way trip must not exceed 50 miles of 
driving distance. Therefore, we decided that the Plan does not have to pre-approve additional LogistiCare 
mileage for an additional two miles for a total of 52 miles.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental implants. 
 
You asked the Plan to pre-approve the dental implants. You say that you have a defective haw that left you 
with the severe underbite and over the years you lost the back teeth due to prior conditions. The Plan denied 
your request. The Plan says the service is not a covered benefit under the plan. The Plan states despite multiple 
attempts, they did not receive medical records from your doctor to show a benefit exception should be made. 
The Plan states there are no medical conditions noted that would put you at risk if you did not have this 
particular treatment. 
 
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. This service is not listed in your 2021 EOC as a covered benefit; 
therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve the dental 
implants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (93793) provided on October 8, 2020. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says there were network providers available. 
 
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 services at issue in this appeal. 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 services (93793) provided on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the ophthalmology service provided on October 
12, 2020. 
 
You asked the Plan to reimburse you for the ophthalmology service. You say that you understand you exceeded 
the limit but you would like the Plan to cover the charge. The Plan denied your request. The Plan says you 
exceeded the authorized limit for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 92014 is 1. The Plan paid the retina specialist claim and the 
ophthalmologist billed a second unit of this code, exceeding the MUE for this date of service. Based on this 
information, we decided that Medicare rules for coverage of the ophthalmology service have not been met. 
Therefore, we decided that the Plan does not have to reimburse you for the ophthalmology service provided on 
October 12, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT, abdomen and pelvis; without contrast material (CPT Code 
74176). 
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee has lower abdominal pain and has 
aches over their body. The Plan denied your request. The Plan says that the provider did not tell the Plan what 
condition the provider thinks the enrollee has; therefore, the CT scan is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our physician reviewer 
found the enrollee still has symptoms despite medical therapy. The requested CT scan is medically 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 the CT scan have been met. Therefore, we decided that the Plan has to pre-
approve CT, abdomen and pelvis; without contrast material (CPT Code 74176).  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 26, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 
laboratory 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 laboratory services provided on November 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (74177, 72128, 72131, 71260) provided 
August 10, 2019. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment was already made for these services. 
 
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 code 74177, 72128, 72131, & 71260 is not supported in the medical record. Specifically, 
payment for these services was already issued under claim number 820202761482261. Based on this 
information, we decided that Medicare rules for coverage of the radiology services have not been met. 
Therefore, we decided that the Plan does not have to pay for radiology services (74177, 72128, 72131, 71260) 
provided August 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
rendered on September 15, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that the copayment is a financial 
hardship. The Plan denied your request. The Plan says the copayment was applied 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 $325 
copayment per day for Medicare-covered diagnostic radiology services.  
 
Review of the file shows that you received a CT scan on September 15, 2020. You have been asked to pay a 
$325 copayment for these services. These services fall within the Medicare-covered diagnostic radiology 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography 
(CT) scan rendered on September 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for replacement leads (A4557) provided on September 4, 2020. 
 
You asked the Plan to pay for the replacement leads. You say that you would like reconsideration because the 
replacement leads are a covered benefit. The Plan denied your request. The Plan says since a TENS unit has 
been purchased in the previous 12 months, the lead wires have been denied. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of lead wires (A4557) more often 
than every 12 months would rarely be reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the replacement leads have not been met. Specifically, the record indicates that a TENS unit was 
purchased on December 4, 2019. There is no documentation as to why the replacement lead wires are 
medically necessary. Therefore, we decided that the Plan does not have to pay for replacement leads (A4557) 
provided on September 4, 2020.