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

We decided that the Plan does not have to pre-approve the power seat elevation feature or upgraded electronics.
You asked the Plan to pre-approve a power seat elevation feature (E2300) and upgraded electronics (E2311, E2313, E2377). You say that the enrollee needs a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says there is not a medical need to control the power options through the joystick and the seat elevation system is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The power seat elevation feature does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. The record shows upper limb strength and function are adequate for the enrollee to control the power options using their own switches which are included in the allowance of the power options. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation feature or upgraded electronics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the $562.70 cost share charged for a 3D nuclear medicine imaging provided on August 26, 2020.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct because you were told it would be $150. The Plan denied your request. The Plan says this cost share is actually less than the normal 20% coinsurance for this type of nuclear scan. Maximus overturned the Plans denial stating the contract was ambiguous. The Plan requested a reopen and stated that the Medicare allowable for this type of nuclear scan is $3200. The contract states nuclear testing can have a 20% coinsurance. The actual cost for this scan could have been $646.06. However, you were only charged $562.70 in this case.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for nuclear medicine imaging. The $150 copayment only applies to general diagnostic radiology. A 3D nuclear scan is not general radiology. The Plan is also correct in stating that you were charged less than the normal 20% coinsurance for this service by the provider. You have been asked to pay the correct amount based the claim submitted by your provided and 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 or reduce the $562.70 cost share charged for a 3D nuclear medicine imaging provided on August 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the scooter provided by an out-of-network provider on February 5, 2021.

You asked the Plan to pay for the scooter. You say that the Plan knew you were going out-of-network and you were told you would receive 80% reimbursement. You say that you want the bill resolved. The Plan denied your request. The Plan says this provider is not a participating provider with 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 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 scooter provided by an out-of-network provider on February 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. The requested Superion spacer is experimental in nature, as more research is needed to show safety and efficacy. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
The Plan references Local Coverage Determination (LCD) L34890 and National Coverage Determination (NCD) 160.27 in their determination; however, these rules are not binding for the services at issue and were not used in the MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve ophthalmology services. You say that you would like to use this provider because you used this provider in the past. The Plan denied your request. The Plan says there are in-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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (64612) provided December 15, 2020.
You asked the Plan to pay for the surgical services. You say that the procedure billed was medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allowable amount.
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 64612 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met.
Therefore, we decided that the Plan does not have to pay for surgical services (64612) provided December 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the outpatient surgical services rendered on February 15, 2021.
You asked the Plan to waive the deductible for these services. You say that the charges are excessive. The Plan denied your request. The Plan says the deductible was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $750 yearly deductible for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on February 15, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the outpatient surgical services rendered on February 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of skilled nursing facility (SNF) services provided from January 29, 2021, through February 27, 2021.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says continuation of SNF services is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy (PT), speech therapy (ST) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee was at a dependent to maximal assist level with functional mobility including requiring a Hoyer lift for transfers. The enrollee required varying assist with activities of daily living. He tolerated a mechanical soft diet and thin liquids. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from January 29, 2021, through February 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair (E0240).
You asked the Plan to pre-approve a shower chair. You say that you need this because of your knee replacement surgery. The Plan denied your request. The Plan says this item is not covered.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement (11042) provided on February 8, 2021.
You asked the Plan to pay for debridement. You say that multiple debridements are billable and payable. The Plan denied your request. The Plan says the billed units exceed the MUE for this code.
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 11042 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of debridement have not been met. Therefore, we decided that the Plan does not have to pay for debridement (11042) provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 4, 2020 to December 10, 2020 by an out of network (OON) provider.
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 were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 office visit provided on November 4, 2020 to December 10, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology office visits to be provided by an OON
provider.

You asked the Plan to pre-approve oncology office visits. You say that you would like a provider who is closer
to your house. The Plan denied your request. The Plan says there are in-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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
oncology office visits to be provided by an OON provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99285, 93010) provided on February 9, 2021.
You asked the Plan to pay for an emergency room visit. You say that this was billed with a payable diagnosis code. The Plan denied your request. The Plan says this was not billed with an appropriate diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. When coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate diagnosis code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug (T36-T50). We find that this claim cannot be paid as billed. Specifically, the service at issue was billed with the primary and only diagnosis of T50.905A, adverse effect of unspecified drugs, medicaments and biological substances, initial encounter. However, the nature of the adverse effect should be coded first, and the nature of the adverse effect was not included on the claim. Based on this information, we decided that Medicare rules for coverage of an emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99285, 93010) provided on February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on October 21, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you were told that there would not be a copayment on the day of surgery. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $45 copayment for specialist visits. The enrollee has been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on October 21, 2020.
We note your complaint about the misinformation you received from the provider and that the charges have now gone to collections. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hearing services provided on February 18, 2021.
You asked the Plan to waive the copayment for hearing services. You say that you thought you were receiving a routine hearing exam and no one explained it to you until after the fact. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $40 copayment for diagnostic hearing exams and a $0 for routine hearing tests. The medical records show that you received diagnostic hearing services on February 18, 2021. Therefore, you are responsible to pay $10, which is less than the $40 copayment. You have been asked to pay $10 for hearing services. Hearing services fall within the hearing 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 hearing services provided on February 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided to the enrollee on September 9, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code E0745-RR-KJ (1 Unit) remains not supported on appeal.
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 E0745 is "Neuromuscular stimulator, electronic shock unit." We find that HCPCS code E0745 is not supported in the medical record. Specifically, the billing provider cannot be verified in this case. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided to the enrollee on September 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide continuous glucose monitor sensors

You asked the Plan to provide continuous glucose monitor sensors (K0553). You say that the enrollee's average
daily glucose levels have decreased since using a CGM. The Plan denied your request. The Plan says criteria is
not met for a CGM therefore supplies are not covered.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of continuous
glucose monitor sensors (K0553) have not been met. Therefore, we decided that the Plan does not have to
provide continuous glucose monitor sensors
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says you do not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The file shows that you are not treated with insulin injections three or more times per day or use of an insulin pump. 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 pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services coded 11042 provided on January
25, 2021.
You asked the Plan to pay for the debridement services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 11042 is 1. You billed 2 units of this code, exceeding the MUE. Based on
this information, we decided that Medicare rules for coverage of the debridement services have not been met.
Therefore, we decided that the Plan does not have to pay for the debridement services coded 11042 provided on
January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve therapeutic CGM. You say that the enrollee has frequent hypoglycemic events with hypoglycemic unawareness. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for a therapeutic CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).