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

We decided that the Plan does not have to provide coverage for transfer from an inpatient rehabilitation facility
to a skilled nursing facility.
You asked the Plan to provide coverage for this transfer. You say that this transfer is medically necessary. The
Plan denied your request. The Plan says the care received at the inpatient rehabilitation facility is a higher level
of care than at a skilled nursing facility. Maximus overturned the Plans denial and stated skilled nursing facility
services were medically necessary. The Plan requested a reopen and stated that the issue was not medical
necessity but that it was not necessary to be transferred from a facility providing the required care. The Plan
states the medical record indicates you were receiving adequate and necessary intensive rehabilitation in the inpatient
rehabilitation facility which was beyond the level of care that would be provided in a skilled nursing facility.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. It was not medically necessary for you to be
transferred to a lower level of care. Medicare rules for coverage of this transfer have not been met. Therefore,
we decided that the Plan does not have to provide coverage for transfer from an inpatient rehabilitation facility
to a skilled nursing facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Pneumatic compressor (E0652), and segmental pneumatic appliance (E0667).
You asked the Plan to pre-approve the Pneumatic compressor, and segmental pneumatic appliance. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is determined through program instructions. In the absence of program instructions, A/B MACS (B) may determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 years. computation of the useful lifetime is based on when the equipment is delivered to the beneficiary, not the age of the equipment. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the beneficiary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Pneumatic compressor, and segmental pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve the Pneumatic compressor (E0652), and segmental pneumatic appliance (E0667).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the acetaminophen (A9270 x 2) provided in an outpatient setting on July 5, 2021.
You asked the Plan to pay for the self-administered drug. You say that you had an ultrasound done because you thought you had a blood clot in your leg. The Plan denied your request. The Plan says the drugs you received
are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under 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 pay for the acetaminophen (A9270 x 2) provided in an outpatient setting on July 5, 2021.
Benefits for the self-administered drug 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: 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 you have foot pain. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal and oral evaluation (D0150, D3331).
You asked the Plan to pre-approve the root canal and oral evaluation. You say that the services are medically necessary. The Plan denied your request. The Plan says these services are not covered under your dental benefit.
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. Root canals are not covered, and oral exams are only covered when performed by a general dentist. Therefore, we decided that the Plan does not have to pre-approve a root canal and oral evaluation (D0150, D3331).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit billed to the enrollee on January 15, 2021.
You asked the Plan to pay for this service as billed. You say that this claim should be paid. The Plan denied
your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial.
The Plan requested a reopen and provided additional information. The Plan says that it has been determined
this claim denied because the procedure billed is inconsistent with the place of service. The provider has billed
this service as an Audio-Only Visit. The claim did not include the Telehealth Modifier for payment
consideration. The appeal also mentions that the enrollee is a Medicaid eligible enrollee, but the records show
the enrollee has a Medicare Advantage Plan contract. The case file includes the appealed claim that shows the
provider has inappropriately billed this service with Modifier "UD", which is used to identify that a claim is for
a provider-administered drug purchased through the 340B Program and to ensure that only eligible claims are
being used to obtain drug manufacturer rebates. We found that the provider needed to bill the Place of
Treatment as Office and with Modifier 95 to show the service was delivered via telehealth.
There are no payment restrictions on distant site practitioners furnishing telehealth services from their home
during the public health emergency. The practitioner should report the place of service (POS) code that would
have been reported had the service been furnished in person. This will allow appropriate payment for services
furnished via Medicare telehealth which, if not for the COVID-19 pandemic, would have been furnished in
person, at the same rate they would have been paid if the services were furnished in person.
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, this claim was
submitted with an inappropriate place of service code. Based on this information, we decided that Medicare
rules for coverage of this service as billed have not been met. Therefore, we decided that the Plan does not have
to pay for an office visit billed to the enrollee on January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on June 
25, 2021. 
 
You asked the Plan to waive the copayment for a spinal canal injection. You say that you do not think you 
should be responsible for the charges. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for outpatient surgery, including services provided at hospital outpatient services.  
 
The record shows that you received a spinal canal injection at an outpatient hospital facility on June 25, 2021. 
A spinal canal injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay 
the $325 copayment.  
 
You have been asked to pay a $325 copayment for a spinal canal injection. A spinal canal injection falls within 
the outpatient surgery, including services provided at hospital outpatient services and ambulatory surgical 
centers 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 a spinal canal injection provided 
on June 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from April 10, 2020, to 
May 1, 2020. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim was submitted after the 12-month filing 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 home health services was not filed until July 12, 2021. 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 home health services provided from April 10, 2020, to May 
1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 17, 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered chiropractic service (code 99204) provided on March 15, 2021.
You asked the Plan to pay for code 99204. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says code 99204 is not covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue under code 99204 is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the non-covered chiropractic service (code 99204) provided on March 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for fine needle aspiration biopsy provided on April 23, 2021.
You asked the Plan to pay for fine needle aspiration biopsy. You say that the services were provided, and payment should be rendered. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 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 fine needle aspiration biopsy. Our coder says that the service is not supported by the medical records. Our coding reviewer found documentation submitted was reviewed and does not meet criteria. Operative report does not include documentation to confirm a fine needle aspiration was distinct procedural service from CPT 32408. Modifier 59 should be used to distinguish a different session or patient encounter, different procedure or surgery, different anatomical site or separate injury.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of fine needle aspiration biopsy have not been met. Therefore, we decided that the Plan does not have to pay for fine needle aspiration biopsy provided on April 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from July 30, 2020 to August 5, 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 submitted records do not support the billed DRG and secondary diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 699 (other kidney and urinary tract diagnoses with complication or comorbidity (cc) - market size, prevalence, incidence, quality outcomes, top hospitals & physicians) and secondary diagnosis code G93.41 (metabolic encephalopathy). 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 these services. Our reviewer says that the submitted records do not support the billed DRG and secondary diagnosis code. Our physician reviewer found the enrollee presented to the emergency department (ED) with complaints of generalized weakness and altered mental status. His labs were consistent with a urinary tract infection. The ED provider notes state, "based on daughters' description of patients baseline mentation I do not feel he is altered but do believe he is more weak than usual." The progress notes state he had baseline mild cognitive impairment. The records do not support a change in mental status that is beyond baseline. The DRG and secondary diagnosis are not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from July 30, 2020 to August 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 24, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective payment systems are payment in full for all inpatient hospital services. We looked at the file and Medicare rules. The file shows that the services were rendered to a hospital inpatient. Payment for these services is included in payment to the hospital. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on May 26, 2021.
You asked the Plan to pay for eyeglasses. You say that your vision changed and that is why you ordered new glasses. The Plan denied your request. The Plan says your benefit maximum has been met. You last received eyewear on January 31, 2020. Per your Evidence of Coverage, the benefit is administered on a rolling calendar year since your last date of service. You would have been eligible for eyewear on January 31, 2022.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows your maximum eyewear benefit has been met. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for manual microdissection (88381) provided on June 3, 2021. 
 
You asked the Plan to pay for manual microdissection. You say that this is a payable code. The Plan denied 
your request. The Plan says this cannot be paid on the same date as 81542. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that many multianalyte assays 
with algorithmic analyses (CPT codes 81493-81599) are DNA or RNA analytic methods that simultaneously 
assay multiple genes or genetic regions. A physician shall not additionally separately report testing for the same 
gene or genetic region by a different methodology (CPT codes 88364-88377).  
 
We find that CPT code 88381 is not supported in the medical record. Specifically, this was billed on the same 
date as 81542. CMS payment policy does not allow separate payment for multiple methods to test for the same 
analyte. Based on this information, we decided that Medicare rules for coverage of manual microdissection 
have not been met. Therefore, we decided that the Plan does not have to pay for manual microdissection 
(88381) provided on June 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis (J7322).
You asked the Plan to pre-approve Hymovis. You say that the request for Hymovis is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, Monovisc and Orthovisc.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Hymovis. Our reviewer says that Hymovis is not medically necessary. Our physician reviewer found the provided documentation does not indicate that enrollee has trialed viscosupplemental treatments such as Orthovisc and Monovisc. The documentation does not outline contraindications or reasons these medications were not considered or that the Plan's additional required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Hymovis is not approved, as step criteria have not been 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 Hymovis have not been met. Specifically, the file shows that the enrollee has not tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Hymovis (J7322).
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 they are medically necessary to assist your physical activity and exercise. 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: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for surgical services provided to the enrollee on December 29, 2020.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. 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 provided additional information. The Plan determined this claim
denied because this service was already paid under a previous claim from the same provider. The records show
both claims were billed under the same physician group. The Medicare policy manual explains that a distinct
services modifier would need to be billed to bypass the edit applied to this claim. Each edit table contains edits
which are pairs of HCPCS/CPT codes that in general should not be reported. Based on the Medicare guidelines,
the second claim was submitted with errors due to the omission of the required modifier.
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 necessary the
appropriate modifier. Based on the documentation provided, this claim cannot be paid as billed due to omission
of a modifier to show each claim was for a separate and distinct service. Medicare billing criteria were not met.
Therefore, we decided that the Plan does not have to pay for surgical services provided to the enrollee on
December 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that this should be a covered benefit. 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 pay for foot orthotics.