Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan does not have to provide coverage for residential inpatient care for the enrollee.

You asked the Plan to provide coverage for residential healthcare. You say that residential care is medically necessary for the enrollee. The Plan denied your request. The Plan says residential care is not covered by the Plan or by Medicare. Maximus overturned the Plans denial stating inpatient mental health care was necessary. The Plan requested a reopen and stated that inpatient hospital facility mental health care was not the request and that the request was for residential care which is not covered.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has limitations on what types of providers can render inpatient mental healthcare. The request was for coverage at a residential rehabilitation center for treatment of an eating disorder. This is not covered by Medicare. Therefore, we decided that the Plan does not have to provide coverage for residential inpatient care for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychotherapy services (90834) provided on May 20, 2020 by an out of network (OON) provider.You asked the Plan to pay forOON psychotherapy services. You say that this provider should be considered in-network.The Plan denied your request. The Plan says the provider is out-of-network and this service was 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 forthe psychotherapy services (90834) provided on May 20, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial denture provided on September 11, 2020.
You asked the Plan to pay for the interim partial denture. You say that you do not have a partial denture, and it
is only a one tooth replacement. The Plan denied your request. The Plan says this service is not covered. The
Plan also says that it was confirmed with the provider's office that you do have a partial denture.
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
interim partial denture provided on September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided the Plan does not have to pre-approve a pneumatic compression device (E0651, E0652 and E0657). 

You asked the Plan to pre-approve a pneumatic compression device. You say that this device 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 that Maximus did not apply the correct LCD criteria.

Our Medical Director looked at the case file and the reopen request.  At issue is coverage for a pneumatic compression device. The Maximus Physician Reviewer determined that the enrollee had failed protracted outpatient therapy. The Plan requested a reopen and stated the medical records do not show a diagnosis of lymphedema or chronic venous insufficiency with ulcers. The medical records show a diagnosis of displaced bimalleolar fracture of right lower leg, subsequent encounter for open fracture type I or II with routine healing, and displaced fracture of body of right calcaneus, initial encounter for closed fracture. On June 4, 2020 there was a complaint of severe swelling in both legs. The physical exam was notable for +3 edema in the right lower extremity distal to the knee. The plan was to proceed with conservative care with compressive socks, exercise and Lasix. Gait therapy was just beginning. Based on the medical records provided, our Medical Director says that the Plan is correct in this case. The documentation does not support that the coverage criteria for a pneumatic compression device as established by LCD L33829 are 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 pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression (E0651, E0652 and E0657) device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe vision services provided September 11, 2020, by an out-of-network provider.You asked the Plan to pay forvision services. You say that you want this to be treated like you visited an in-network provider. You went to them last year and submitted a reimbursement form and was reimbursed and you would like the same thing to happen this year.The Plan denied your request. The Plan says enrollee's must use a participating provider for coverage of routine vision services.Medicare generally does not coverroutine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when rendered by a participating provide We looked at the file and the Plan's rules. Enrollee's must use a participating provider for routine coverage including routine exam, retinal imaging and eyewear allowance. Based on this information, we decided that the Plan's rules for coverage of vision services have not been met.Therefore, we decided that the Plan does not have to pay forthe vision services provided September 11, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis (LSO) rendered on August 22, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary.We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 forthe lumbar-sacral orthosis (LSO) rendered on August 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided by a participating provider on September 1, 2020.
You asked the Plan to waive the copayment for vision services. You say that you do not agree with paying this much for all these services. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $45 copayment for vision care/in-network/specialist's office. You have been asked to pay a $45 copayment for vision services. The correct copayment has been applied to the services that were provided. Vision services fall within the vision care/in-network/specialist's office 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 vision services provided by a participating provider on September 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea sleep study for the enrollee.You asked the Planto pre-approvethe study. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is 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 the study. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found an attended PSG is not medically necessary. Theenrollee has a known diagnosis of OSA, and has been using CPAP since 2011, with benefit, as documented in the medical records. The current device has become non-functionaland is not reparable according to the vendor. The enrollee qualifies for coverage of a replacement CPAP device. A repeat PSG is not needed because the patient had been doing well on CPAP at the current settings.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rulesfor coverage of the study have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea sleep study for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a fall associated with a seizure. Your medical conditions are stable. There are no medical needs requiring inpatient admission.There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a needfor physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofIRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital care provided from May 25, 2020, to May 29, 2020.You asked the Plan to waive the copayment forthe inpatient hospital care. You say that you do not believe you should pay the copayment.The Plan denied your request. The Plan says the copayment processed correctly 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 $300 copayment per for day 1-5 for inpatient hospital care. You have been asked to pay a total cost share of $1200 for the inpatient hospital care (4 inpatient days x $300 copayment). The services provided fall within the inpatient hospital care 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 forthe inpatient hospital care provided from May 25, 2020, to May 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe transportation services provided on September 22, 2020.You asked the Plan to pay forthe transportation services. The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services.Therefore, we decided that the Plan does not have to pay forthe transportation services provid on September 22, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgical services rendered. 
 
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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -74 is to be billed by a facility. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 92920 with 
modifier -74. The claim was submitted as a physician claim and not an outpatient facility claim, which is not 
appropriate billing of modifier -74. Therefore, we decided that the Plan does not have to pay for the outpatient 
surgical services rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on July 31, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for these services was not filed until November 3, 2020. This means that more than one calendar year from the date of service had passed before a claim wasfiled.Therefore, we decided that the Plan does not have to pay forthe services rendered on July 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvenon-emergent transportation by taxi (A0100).You asked the Plan to pre-approvea taxi. You say that the service is medically necessary.The Plan denied your request. The Plan says the service requested exceeds the benefits allowed maximum.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. The Plan covers a maximum of 40 one way trips to plan approved locations every year trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Specifically, the service requested exceeds the Plan's maximum allowed benefit. This means the service is not covered.Therefore, we decided that the Plan does not have to pre-approvenon-emergent transportation by taxi (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

e decided that the Plan does not have to pay the in network rate forthe periapical x-ray (D0220) provided on October 1, 2020.You asked the Plan to pay the in network rate forthe periapical x-ray. You say that you have been going to this dentist and they did not tell you that you are not covered. You say that you do not want to pay for $200. You also say that you were informed that you have coverage.The Plan denied your request. The Plan says the periapical x-ray 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 the in network rate forthe periapical x-ray (D0220) provided on October 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care.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 care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF)care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora cardiovascular stress test provided on July 29, 2020.You asked the Plan to waive the copayment forstress test. You say that you were told that the copayment for this would only be $10.The Plan denied your request. The Plan says the copayment amount the enrollee is being charged is correct.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 $150 copayment for stress test. The enrollee has been asked to pay the allowed amount of $69.37, which is less than the $150 copayment for stress test. Stress test falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 fora cardiovascular stress test provided on July 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Prolia injection rendered on May 27, 2020.You asked the Plan to waive the coinsurance forthese services. You say that the provider told you this was the best option for you.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for chemotherapy and all other drugs covered under Medicare Part B. Review of the file shows that you received a Prolia injection on May 27, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the chemotherapy and all other drugs covered under Medicare Part B 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, wedecided that the Plan does not have to waive the coinsurance forthe Prolia injection rendered on May 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe x-ray provided on September 17, 2020.You asked the Plan to waive the copayment forthe x-ray. You say that you have never had a copayment for radiology services. You say you will not pay this copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $35 copayment for each outpatient x-ray, diagnostic procedure and test. You have been asked to pay a $35 copayment for the x-ray. The x-ray falls 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 forthex-ray provided on September 17, 2020.Our decision is only about the September 17, 2020 service. If you have any questions about prior years billing, please contact the plan directly
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe PET scan provided on August 24, 2020.You asked the Plan to pay forthe PET scan. The Plan denied your request. The Plan says an appropriate diagnosis code was not billed.The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis codes that may be used. The billed diagnosis codes in this case are not listed as appropriate diagnosis codes for the provided PET scan.Therefore, we decided that the Plan does not have to pay forthe PET scan provided on August 24, 2020.