Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on  February 28, 
2020, through March 8, 2020 and March 13, 2020, through March 19, 2020. 
 
You asked the Plan to pay for SNF care. You say that the services rendered were medically necessary. The Plan 
denied your request. The Plan says from February 28, 2020 through March 8, 2020 and from March 13, 2020 
through March 19, 2020 the member no longer required daily skilled care from either a nurse or a therapist. 
Continued assistance with routine daily activities could be safely provided at the custodial level of care as it 
had been before. 
 
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 pay for SNF care. Our reviewer says that daily 
skilled services were not necessary. Our physician reviewer found, based on the medical records provided, this 
patient did not require the services on an inpatient basis, in a skilled nursing facility setting.  Services in a long-
term care facility appear custodial for the dates in question. 
 
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 pay for skilled nursing facility (SNF) care provided on February 28, 2020, through March 19, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility discharge day management provided on 
June 18, 2019. 
 
You asked the Plan to pay for the nursing facility discharge day management. You say that your submission 
was untimely because you did not receive proper notice of the enrollee's benefit determination. You also say 
that medically necessary services were provided to the enrollee in good faith. The Plan denied your request. 
The Plan says Medicare denies a claim if it is not received by the Plan within 12 months or 1 calendar year 
from the date when the services were rendered. The Plan also says that the claim was received on July 9, 2020, 
which is past the allowed 12 month timeframe. 
 
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 the nursing facility discharge day management was not filed until June 18, 
2019. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for the nursing facility discharge day 
management provided on June 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, panoramic x-
ray, extraction, and removal of impacted tooth provided on May 13, 2020 by an OON provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, panoramic x-ray, extraction, and 
removal of impacted tooth. You say that you were advised by the Plan that you should go OON, because the 
two in-network oral surgeons were closed because of COVID-19. The Plan denied your request. The Plan says 
these services were rendered by a provider who is not in the Plan's network. The Plan also says that you 
contacted the Plan and were provided with oral surgeons that were in-network, and were also advised if you go 
OON and pay out of pocket that you could file for reimbursement. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation, panoramic x-ray, extraction, and removal of impacted tooth provided on May 
13, 2020 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra eye drops. 
 
You asked the Plan to pre-approve the Xiidra eye drops. You say that the enrollee had a reaction to Restasis. 
You also say that the enrollee has used many over the counter drops. The Plan denied your request. The Plan 
says this drug is not covered for the enrollee's condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra eye drops.  
 
Benefits for the Xiidra eye drops may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from July 12, 
2020, to July 30, 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 this must be reported with the correct type of bill. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the denied services are not supported in the medical record. Specifically, this claim was not billed 
with a valid type of bill. The claim has 0437, rather than 032(x) as the type of bill. 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 home health services provided to the enrollee from July 12, 2020, to July 30, 
2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve dental services (D6245, D6740 for tooth #2, 4, 5) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the information sent by the dentist does not show a denture cannot be used to 
replace the missing teeth. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial. The plan has made a clinical, rather 
than administrative denial, which means that they had medical records or x-rays of some sort to make this 
decision. No clinical records were provided to MAXIMUS for review. Therefore, we decided that the Plan has 
to pre-approve dental services (D6245, D6740 for tooth #2, 4, 5) for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on July 15, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for an OON office visit. You say that this was medically necessary. The Plan denied 
your request. The Plan says this 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 has network providers 
available who can provide 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 (99213) provided on July 15, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on June 4, 2020, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer the services. 
 
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 has network providers 
available who can provide 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 lab work provided on June 4, 2020, by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve COOLIEF cooled radiofrequency ablation. 
 
You asked the Plan to pre-approve COOLIEF cooled radiofrequency ablation. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. 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 COOLIEF cooled radiofrequency 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee presents with chronic bilateral knee pain. Pain 
is reported grade 8 out of 10 on average. Functional limitations are noted in activities of daily living. The 
enrollee is status post right total knee replacement in 2002 and right knee patellar resurfacing in 2018. The 
enrollee has failed to achieve adequate improvement with prior activity modification, ice, topical NSAIDs, 
acetaminophen, and physical therapy. She underwent bilateral genicular nerve blocks with 90-100% pain relief 
reported. Current evidence based medical literature do not fully support COOLIEF over standard conservative 
treatment citing the need for more research. There is a lack of large volume, long-term peer-reviewed outcome 
studies to support the use of these procedures for this patient as discussed above. Additionally, there is no 
evidence that this enrollee has failed other standard injections, such as corticosteroid injection or 
viscosupplementation. This request for COOLIEF does not meet Medicare criteria as it would be considered 
investigational. COOLIEF would not be considered the standard of care or medically reasonable and necessary 
for treatment of this enrollee's medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of COOLIEF cooled radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve COOLIEF cooled radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the intravenous infusions and daptomycin 
injections provided from February 11, 2020, through February 29, 2020. 
 
You asked the Plan to waive the cost share for the intravenous infusions and daptomycin injections. You say 
that you were unable to determine how much your copayment would be. You say that if you were aware of the 
cost you may have opted out of the services. The Plan denied your request. The Plan says the cost share 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 for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, 
including but not limited to hospital or other facility charges and physician or surgical charges and 20% 
coinsurance for each Medicare-covered Part B drug.  
 
 
You have been asked to pay a total of $3,941.22 for the intravenous infusions and daptomycin injections.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
February 11, 2020- 
February 28, 2020 
Intravenous 
Infusions 
$177.20/Infusion $325/Infusion $3,189.60 
($177.20 x 18 infusions) 
February 29, 2020 Intravenous 
Infusion 
$354.40 $325 $325 
February 11, 2020- 
February 17, 2020 
Daptomycin 
Injections 
$176.40/Injection 20% of $176.40 for 
each injection 
$246.96 
($35.28 x 7 injections) 
February 11, 2020- 
February 17, 2020 
Daptomycin 
Injections 
$177.60 20% of $177.60 for 
each injection 
$164.64 
($23.52 x 7 injections) 
February 18, 2020 Daptomycin 
Injection 
$545.92 20% $15.02-Met max out-of-
pocket 
TOTAL:    $3,941.22 
 
The intravenous infusions fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The daptomycin injections fall within 
the "Medicare Part B Prescription Drugs" 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 cost share 
for the intravenous infusions and daptomycin injections provided from February 11, 2020, through February 
29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty is covered when specific criteria are 
met. 
 
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 multiple spinal 
fractures. There is no documentation that the fracture is less than six weeks old. The criteria for coverage are 
not met and the kyphoplasty is 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 kyphoplasty.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home therapy services provided on June 25, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coding 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 services. Our reviewer says that the use 
of CPT codes 97116 and 97110 is not supported by the records provided. Our coding reviewer found that the 
Visit Note Report was performed and signed by a Physical Therapy Assistant (PTA). CPT 97116 and CPT 
97110 would be inappropriate to bill for this service. Services performed by a PTA would be billed with the 
appropriate Healthcare Common Procedure Coding System (HCPCS) code. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the home therapy services provided on June 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (85027, 87497) provided May 14, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these services are not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes 85027 & 87497 are not supported in the medical record. Specifically, the record shows 
payment was issued for facility services on the same date of service. Payment for the lab services is included in 
the Hospital Prospective Payment System (PPS) rate. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for lab services (85027, 87497) provided May 14, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on March 11, 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. The rules say that inpatient services must be billed with POS code 21. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure codes 95938, 95861, 
and 95937 with POS code 15 for a mobile unit; however, the file shows that the services were performed while 
the enrollee was under inpatient hospital status and should be billed with POS code 21. 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 testing services rendered on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office consultation to be provided by an out of 
network (OON) Ophthalmologist. 
 
You asked the Plan to pre-approve an office consultation to be provided by an OON Ophthalmologist. You say 
that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the 
requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are equally 
qualified in-network Ophthalmologists available to you that can provide the services you are requesting. 
 
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 
an office consultation to be provided by an out of network (OON) Ophthalmologist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a biopsy provided on February 3, 2020. 
 
You asked the Plan to pay for the biopsy. 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 
services 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 a biopsy provided on February 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for home health services with an out-of-
network provider for the enrollee. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are 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 
a referral for home health services with an out-of-network provider for the enrollee.