Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a hearing aid purchased out of network on August 6, 2021.

You asked the Plan to pay for out of network hearing aids. The Plan denied your request. The Plan says out of
network hearing aids are not covered. Maximus overturned the Plans denial. The Plan requested a reopen and
stated that Maximus did not apply the correct contract language.

The Plan is correct in this case. 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 provider in this case is not a
network provider with the Plan. The Plan did not pre-approve the hearing aid. 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 a hearing aid purchased out of network on August 6, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services billed to the enrollee from July 13, 2021, to
August 11, 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 only a portion of this claim is the Plans responsibility. The Plan states that because the
enrollee revoked hospice on July 8, 2021, Original Medicare covers all services until July 31, 2021, per the
billing guidelines. The claim should be split to bill Original Medicare for dates of service July 13, 2021, to July
31, 2021, and the Plan should be billed separately for August 1, 2021, to August 11, 2021.

Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that technically
Maximus agreed with the Plan, but the claim cannot be split due to the hospice codes and must be billed on two
separate claims.

The Plan is correct in this case. Medicare rules say that Original Medicare, not the Plan, is responsible for all
Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the
first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on July 8, 2021. Therefore, one claim for services provided
from July 13, 2021, to July 31, 2021, should have been submitted to Original Medicare and a separate claim
should have been submitted to the Plan for August 1, 2021, to August 11, 2021. Therefore, we decided that the
Plan does not have to pay this claim as billed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services billed to the enrollee for July 1, 2021, and billed under code 99443.

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 were not met. Maximus overturned the Plans denial for insufficient claim information. The Plan requested a reopen and demonstrated that the provider billed code 99215 for June 24, 2021, and that code was paid by the Plan. The claims for services July 1, 2021, is within the 7 days allowed per the telephone evaluation and management services. Therefore, code 99443 would be included in the previously billed claim and would not be paid separately.

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 claim history shows code 99215 was billed by the same provider with a related diagnosis code of C34.31 within seven days of the telehealth service. Therefore, this second claim was inappropriately billed. Therefore, we decided that the Plan does not have to pay for telehealth services billed to the enrollee on July 1, 2021, and billed under code 99443.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine disposable supplies (A0382 and A0398) provided 
on April 15, 2022. 
 
You asked the Plan to pay for the routine disposable supplies. You say that you broke your hip and needed 
ambulance transportation to get to the hospital. The Plan denied your request. The Plan says these services are 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that an ambulance must have customary patient care 
equipment and first aid supplies that are considered part of the general ambulance service, and payment for 
them is included in the payment rate for the transport. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the routine disposable supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for the routine disposable supplies (A0382 and A0398) provided on April 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for breast imaging provided September 30, 2021.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus applied the incorrect billing criteria. The Plan showed that codes
77063 and 77067 are inclusive to code 77066 which was billed on a separate claim for the same date of service.
The Plan states a Procedure to Procedure (PTP) edit exists between these code pairs with a modifier indicator
of "1", which states modifiers are allowed, however the appropriate National Correct Coding Initiatives (NCCI)
modifier was not billed on the second claim.

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 required
modifier. Therefore, we decided that the Plan does not have to pay for breast imaging provided to the enrollee
on September 30, 2021, and billed under code 77067.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network hearing aids purchased November 1, 2021.

You asked the Plan to pay for out of network hearing aids You say that these hearing aids should be covered by
the Plan. The Plan denied your request. The Plan says out of network hearing aids are not covered. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
contract language.

The Plan is correct in this case. 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 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 out of network hearing aids purchased November 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided to the enrollee from February 1,
2021, to April 22, 2021, to include the HCHC Glucose blood test ($196) and HCHG Routine venipuncture test
($520).

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 were not met. Maximus overturned the Plans denial for
insufficient claim information. The Plan requested a reopen and states that while a portion of this claim was
paid, the HCHC Glucose blood test ($196) and HCHG Routine venipuncture test ($520) remains denied as
inpatient services provided by a floor nurse are not separately billable

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, while a portion
of this claim was reprocessed and paid, the HCHC Glucose blood test ($196) and HCHG Routine venipuncture
test ($520) were billed separately in error. Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the HCHC Glucose blood test ($196) and HCHG
Routine venipuncture test ($520) provided to the enrollee from February 1, 2021, to April 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on March 30, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it was the facilities responsibility to obtain an 
authorization and you would like the claim paid. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 a home health visit provided on March 30, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to a power scooter. 
 
You asked the Plan to pre-approve power scooter. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the denial of authorization for these repairs is correct, because this scooter is not 
being used primarily in your home and you already have a power wheelchair for use in the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve repairs to a power scooter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on March 21, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you were told about an x-ray so youre 
not going to pay for one. The Plan denied your request. The Plan says the copayment applied 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). Your contract with the Plan clearly says that you must pay $35 
copayment for each basic imaging service (e.g., general x-rays or ultrasound). 
 
You have been asked to pay $35 copayment for an x-ray. X-rays fall 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 
for an x-ray provided on March 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the bone marrow aspirate necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested bone marrow aspirate in the setting of spine fusion surgery, in this case, 
is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for outpatient rehabilitation services
provided to the enrollee from April 10, 2018, to July 26, 2019.

You asked the Plan to waive this cost share. You say that the enrollee was not billed for these copayments. The
Plan denied your request. The Plan says this cost share was charged per the Plan contract agreement. Maximus
partially overturned the Plans denial due to insufficient benefit information submitted in the original case file
for all dates appealed. The Plan requested a reopen and provided the required information.

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). The enrollee's contract with the
Plan clearly says that enrollees must pay a $20 copayment for each outpatient rehabilitation visit.

The enrollee has been asked to pay the correct amount based on their contract with the Plan. This cost sharing
is a contractual obligation the enrollee agreed to pay when they enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayments charged for outpatient rehabilitation services provided to the
enrollee from April 10, 2018, to July 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for hearing services and hearing aids provided on October 28, 2021.

You asked the Plan to pay for out of network services hearing aids from a commercial retailer. You say that
these hearing aids should be covered the Plan. The Plan denied your request. The Plan says the provider was
not in network and is not a Medicare eligible provider. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct contract language.

The Plan is correct in this case. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided hearing services and hearing aids.

The Plan did not pre-approve these hearing aids or this provider. You did not follow your contract rules when
purchasing these hearing aids. Therefore, we decided that the Plan does not have to pay for hearing services
and hearing aids purchased on October 28, 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 a therapeutic CGM. You say that this device is medically reasonable and 
necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not 
been satisfied for this CGM. 
 
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 therapeutic 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in bath tub. 
 
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 covered. 
 
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 a walk-in bath tub.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the complete ultrasound of one breast 
provided on May 18, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that during your routine mammogram 
an ultrasound was performed, and you thought it would be considered preventative care and be fully covered. 
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 $50 
copayment for each ultrasound.  
 
 
 
 
 
 You have been asked to pay a $50 copayment for an ultrasound. An ultrasound 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 for the complete ultrasound of one breast provided on May 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Enhertu for the enrollee.

You asked the Plan to provide coverage for the requested drug. You say that this drug 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 criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Enhertu. The
Maximus Physician Reviewer determined that Enhertu was reasonable. Medically necessary, safe, and effective
for the enrollee in this case. The Plan requested a reopen and argues the medical literature and compendia is
supportive of Enhertu only in the setting of HER2-positive disease. The Plan states that there is no support for
the drug in the setting of triple negative disease.

The medical records show the enrollee is a 70-year-old woman with a diagnosis of metastatic breast cancer. It
is noted on the Chemotherapy Plan New Regimen that the enrollee's cancer is triple negative but HER2 2+
with a pathogenic HER2 mutation. The Surgical Pathology Report documents that the HER-2/neu was
equivocal (2+): Incomplete and/or weak to moderate circumferential membrane staining in >10% of invasive
tumor cells or Complete, intense, circumferential membrane staining in <=10% of invasive tumor cells. Testing
was negative for amplification of HER2/neu gene. Therefore, the Plan is correct in this case. It was determined
the documentation does not support that Enhertu was medically reasonable, safe and effective for this enrollee,
as testing did not demonstrate that the enrollee's cancer was HER2 positive.

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 requested drug have not been met. Therefore, we decided that the Plan does
not have to provide coverage for Enhertu for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve a repeat epidural steroid injection. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat epidural steroid injection (ESI) are 
covered when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function for at least three months. 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Review of the file shows that the enrollee had an epidural injection 
where it provided 80% pain relief for two days. This means repeat injection criteria have not been met. Based 
on this information, we decided that Medicare rules for coverage of a repeat epidural steroid injection have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a repeat epidural steroid injection 
(ESI).