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

We decided the Plan does not have to pay for lab services provided from June 9, 2020, to April 2, 2021.
You asked the Plan to pay for these services. You say that these services should be covered for the enrollee by
the Plan. The Plan denied your request. The Plan says they were the secondary payer or secondary insurer at
the time of service and this claim must be submitted by the primary payer before this Plan can review the
services for payment.
We overturned the Plans denial stating the case file did not contain sufficient information to show the
Plan attempted all the steps for coordination of benefits. The Plan requested a reopen and provided additional
information.
The Plan indicated that they reached out to obtain the explanation of benefits from the primary insurance
carrier, but the documentation has not submitted back to this Plan. It is noted the primary payer indicated this
process may take up to 30 days. Once this Plan as the secondary payer receives the required information from
the primary payer that they have reviewed these charged, this Plan will process the enrollee's claim.
Based this information, the Plan is correct in this case. The Plan must follow Medicare rules. The rules state
that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This
means that the Plan is not responsible for paying for services until the claim for those services has gone to the
primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans
can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to
the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer.
Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.
While the above suggestions for coordination of benefits are ways for the Plan to assist in resolving the issue,
the Plan is not required to perform all three as previously stated by us. The Plan has met its obligation
with regards to coordination of benefits. Specifically, the Plan has contacted the primary insurer for further
information regarding the requested explanation of benefits, which the primary insurer indicated could take up
to 30 days to produce. The Plan has indicated once this happens the claim will be reviewed by them as the
secondary payer. As the secondary insurer, the Plan cannot be held responsible for these services until the
primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to
pay for lab services provided to the enrollee from June 9, 2020, to April 2, 2021.
It should be noted also that on August 19, 2021, the Plan submitted a notice to comply and pay for these
services bases on our original decision.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to provide coverage for an oral splint to TMJ pain.
You asked the Plan to pre-approve an oral splint to treat TMJ pain for the enrollee. You say the oral splint is
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
We overturned the Plans denial stating the documentation supports the criteria for coverage for an oral
splint for treatment of the enrollee's TMJ pain. The Plan requested a reopen and stated that there is no
documentation to show the TMJ diagnosis or treatment is a secondary cause to an injury of the jaw or
secondary to other disease, therefore it is not covered by the Plan or by Medicare.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare covers
treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must
also be medically reasonable and necessary. These services are a dental treatment for relieving TMJ pain, but
the are not a medically necessary treatment of the jaw to treat TMJ as a secondary diagnosis.
Medicare and the Plan do not cover these dental services. Medicare criteria for treatment of TMJ are not met.
Therefore, we decided that the Plan does not have to pre-approve an oral splint to treat temporomandibular
joint (TMJ) pain for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgery services provided on October 20, 2020.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says these services must be addressed by the primary payer before they can
be reviewed by this Plan, your secondary payer at the time of service.
We overturned the Plans denial stating the Plan had not attempted to contact the primary payer on your
behalf. The Plan requested a reopen and provided additional documentation. The Plan provided confirmation of
the primary payer at that time of service and has reached out to obtain an explanation of benefits from the
primary insurance carrier. This documentation has not yet been obtained by the Plan. According to the primary
payer, this process may take up to 30 days. The Plan states once they receive the primary payer's explanation
of benefits for review of this service, this claim will be processed.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules state that Medicare plans are
considered secondary insurers when an enrollee has another type of insurance. This means that the secondary
Plan is not responsible for paying for services until the claim for payment has been reviewed by the primary
payer. The Plan has met its obligation with regards to coordination of benefits by identifying and reaching out
to the primary payer on your behalf. As the secondary payer, the Plan cannot be held responsible for these
services until they are addressed by the primary carrier and that insurer has denied the claim for these services.
Therefore, we decided that the Plan does not have to pay for surgery services provided on October 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract removal surgery for the enrollee to be provided
by an out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that these services are medically necessary for the
enrollee. The Plan denied your request. The Plan says that these services are available in-network.
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
cataract removal surgery for the enrollee to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous therapeutic glucose monitor.
You asked the Plan to pre-approve a continuous therapeutic glucose monitor. You say that this request is
medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage
have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections. Based on this information, we decided that Medicare rules for coverage of a continuous
therapeutic glucose monitor have not been met. Therefore, we decided that the Plan does not have to preapprove
a continuous therapeutic glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on
January 22, 2021
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria are not met. Maximus overturned the Plan denial for
insufficient information in the case file regarding the claim issue. The Plan requested a reopen and provided
additional information. The Plan states this claim has denied because the provider billed this service
inappropriately. Per the NPI registry, the billing provider has a taxonomy code for a Registered Nurse/
Registered Nurse First Assistant.
The Medicare Claims Processing Manual Chapter 12, Section 20.4.3, procedures billed with the assistantat-
surgery physician modifiers -80, -81, -82 or the AS modifier are subject to the assistant-at-surgery policy
when billed by physician assistants, nurse practitioners and clinical nurse specialists. Code 49505 was billed
with the "AS" modifier. However, the billing provider is not listed per the NPI as an eligible provider type for
the services provided.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, the taxonomy
code for the billing provider indicates this provider is not eligible to bill an assistant surgeon code. Medicare
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to
pay for assistant surgeon services provided to the enrollee on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for anesthesia services (00912) provided on April 19, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information. The Plan says that this claim denied because the
provider billed this service with an inappropriate modifier. The claim image shows the provider has billed this
service with modifier QZ which indicates a CRNA service: without medical direction by a physician. The
provider should have billed this service with modifier QK which indicates: Medical direction of 2, 3 or 4
concurrent anesthesia procedures involving qualified individuals. This modifier limits payment to 50% of
the amount that would have been allowed if personally performed by an anesthesiologist or non-supervised
CRNA.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly.
Providers must report services with the appropriate codes and when required the appropriate modifiers.
In this case, this claim cannot be paid as billed due to the omission of the appropriate modifier. Medicare rules
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for
anesthesia services (00912) provided to the enrollee on April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided on March 2, 2021, under the
Medicare benefit.
You asked the Plan to pay for these services under the Medicare benefit. You say that you do not believe this
bill is correct. The Plan denied your request. The Plan says these services must be addressed under your
Medicaid benefit. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional
information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid
eligible. The Plan included documentation to show that you are Medicaid eligible.
The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because
Medicaid is generally the payer of last resort.
Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care,
personal care, and home- and community-based services). These services qualified under the Medicaid
coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are
covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid
coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits.
Therefore, we decided that the Plan does not have to pay for physician services provided on March 2, 2021,
under the Medicare benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for durable medical equipment.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says medically necessary care is available in-network. 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 out-of-network referral for durable medical equipment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on April 2, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary visit. You say that the provider relies on facility staff to verify eligibility and obtain the proper authorization. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on April 2, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 enrollee does not meet criteria for IRF admission. 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 nonsurgical management of
lumbar fractures after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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 inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your condition is severe, and shoes are
recommended by your Specialist. The Plan denied your request. The Plan says this item is not a covered
benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 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 pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you did not require skilled therapy to establish
a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an
inpatient basis, at a SNF level of care at the time of discharge from the hospital.
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-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-sterile gloves.
You asked the Plan to pre-approve the gloves. You say that there are multiple open wounds that need to be cleaned daily. The Plan denied your request. The Plan says reusable disposable supplies are 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 item at issue in this appeal 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. Therefore, we decided that the Plan does not have to pre-approve non-sterile gloves.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 there are no complex nursing or rehabilitation needs.
The enrollee's needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-chek test strips.
You asked the Plan to pre-approve Accu-chek test strips. You say that these are necessary for you. The Plan denied your request. The Plan says that Continuous Glucose Monitoring (CGM) products obtained through the pharmacy are limited to Dexcom G6 products and Abbott Freestyle Libre products.
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must document in the beneficiary's medical record the reason why the specific brand or mode of delivery is necessary to avoid an adverse medical outcome. We looked at the file and Medicare rules. The file does not include any documentation from your physician documenting why you require this specific brand of test strips. Without this, medical necessity cannot be established. Therefore, we decided that the Plan does not have to pre-approve Accu-chek test strips