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

We decided that the Plan does not have to provide coverage for SNF services for the enrollee.
You asked the Plan to provide coverage for continued skilled nursing facility services for the enrollee. You say
that at the time of the appeal in July 2021, skilled nursing facility services were necessary for the enrollee. The
Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the
Plan administratively as the case file lacked the required notice of non-coverage documentation. The Plan
requested a reopen and provided the required documentation.
Based on the medical records provided at the time of the appeal, we now find the Plan was correct in its denial
for continued service. 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. Physical
therapy had ended on July 16, 2021. The enrollee did not require daily skilled therapy or daily skilled nursing
services at an inpatient level of care. At the time of the appeal, the care required by the enrollee was custodial
in nature, which is not covered by Medicare. Therefore, we decided that the Plan does not have to provide
coverage for skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675), and segmental
gradient pressure appliance (E0673), provided on August 3, 20221.
You asked the Plan to pay for a pneumatic compression device. You say that the items were medically
necessary. The Plan denied your request. The Plan says the pneumatic compression device is not covered by
Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675), and segmental gradient pressure appliance (E0673), provided on August 3, 20221.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for codes 12002 and 99285 provided on January 2, 2021.
You asked the Plan to pay this claim. You say that these services should be paid by the Plan. The Plan denied
your request. The Plan says Medicare billing criteria were not met. Maximus partially overturned the Plans
denial. The Plan requested a reopen and stated that code 27840 was paid prior to the original decision and that
only codes 99285 and 12002 were in dispute. The Plan stated that it since it was agreed the denial for codes
12002 and 99285 should be upheld, the IRE technically agreed fully with the Plans denial.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case code 27840 was previously paid and should not have been reviewed. Both
the Plan and the IRE concurred codes 12002 and 99285 were not supported by the information submitted and
were not billed with the appropriate modifier. Therefore, we decided the Plan does not have to pay for codes
12002 and 99285 provided on January 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 22, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport mileage coded as A0425 provided to the
enrollee on April 7, 2021.
You asked the Plan to pay this claim. You say that this transport and mileage should be covered by the Plan.
The Plan denied your request. The Plan says the Medicare billing criteria for reporting mileage were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not interpret
the guidelines correct. The rules say that effective for claims with dates of service on and after January 1, 2011,
ambulance providers and suppliers must report mileage units rounded up to the nearest tenth of a mile for all
claims (except hard copy billers that use the UB-04) for mileage totaling less than 100 covered miles.
Providers and suppliers must submit fractional mileage using a decimal in the appropriate place (e.g., 99.9).
Contractors shall truncate mileage units with fractional amounts reported to greater than one decimal place,
e.g., 99.99 will become 99.9 after truncating the hundredths place.
For trips totaling 100 miles and greater, suppliers shall continue to report mileage rounded up to the nearest
whole number mile (e.g., 999). Contractors shall truncate mileage units totaling 100 and greater that are
reported with fractional mileage (e.g., 100.99 will become 100 after truncating the decimal places). For mileage
totaling less than 1 mile, providers and suppliers must include a "0" prior to the decimal point (e.g., 0.9). For
ambulance mileage HCPCS only, Carrier/A/B MACS shall automatically default "0.1" unit when the total
mileage units are missing in Item 24G of the Form CMS-1500 paper claim. Claim missing the total mileage
units will be returned.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report ambulance transport with the correct mileage. In this case, the claim submitted did not properly record
the mileage based on the Medicare billing guidelines. Medicare rules for coverage of this claim have not been
met. Therefore, we decided that the Plan does not have to pay for ambulance transport mileage coded as A0425
provided to the enrollee on April 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on October 1, 2021, and October 2, 2021.
You asked the Plan to pay for the self-administered drugs. You say that all the drugs you took were prescribed by your doctor and are covered under Medicare. The Plan denied your request. The Plan says self-administered drugs are not covered under Part B of Original Medicare and are not covered under the Part B medical benefit plan.
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 self-administered drugs provided on October 1, 2021, and October 2, 2021.
Benefits for the self-administered drugs 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 a FreeStyle Libre 14 day reader.
You asked the Plan to pre-approve the FreeStyle Libre 14 day reader. You say that the enrollee likes the reader better than the finger pricks. You also say that the enrollee was adamant that this is what she wanted because it will help with her levels. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the FreeStyle Libre 14 day reader. The Plan also says that you are not using insulin shots 3 or more times per day, and you are not using an insulin pump.
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 the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the FreeStyle Libre 14 day reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 14 day reader.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic mammography (77065) provided on August 2, 2021.
You asked the Plan to pay for the diagnostic mammography. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has denied correctly based on Medicare coding regulations.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 77065 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the diagnostic mammography have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic mammography (77065) provided on August 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan does not have to pre-approve 36 out of network physician visits.
You asked the Plan to pre-approve 44 out of network physician visits. You say that it is necessary to use this provider due to the language barrier. The Plan denied your request. The Plan says while 8 visits have been approved to allow transition back into the network, the remaining visits are not approved. Maximus overturned the Plans denial for continuity of care. The Plan requested a reopen and stated that you left the Plan as of December 31, 2020 and this care could have been provided in network.
The Plan is correct in this case. The provider in this case is not a network provider with the Plan. The Plan authorized enough transition visits through the course of the enrollment with the Plan. Had Maximus been aware that you were going to disenroll at the end of the year, requested visits would not have been appropriate. Therefore, we decided that the Plan does not have to pre-approve the remaining 36 out of network physician visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Eliquis for the enrollee.
Benefits for this 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided to the enrollee on June 1, 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 were not met. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and provided additional information. The
Plan states a National Correct Coding Initiatives (NCCI), Procedure to Procedure (PTP) edit exists between
codes 77001 and 71045. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI
are allowed. However, an appropriate NCCI modifier was not billed with this PTP code edit. The Plan further
noted code 77001 was previously billed by the same provider on a different claim number and was paid by the
Plan on August 12, 2021. The Plan provided the documentation to support these statements.
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 modifiers.
In this case, this claim cannot be paid as billed due to the omission of a required modifier. In addition, the Plan
provided documentation to show this service had been previously paid. Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045)
provided to the enrollee on June 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Movantik for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the patient's treatment
long term use of opiate analgesic. The Plan denied your request. The Plan says that this is not covered under
Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Movantik for the enrollee.
Benefits for this 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this device has not been shown to be safe and effective in long term studies and there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of decompression.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed. Our physician reviewer found that your condition does not meet criteria for coverage of these services.
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 the Vertiflex device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational and physical therapy provided on September 7, 2021, to September 28, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for occupational and physical therapy. You say that you were unaware that the patient had a Medicare Replacement Plan and you billed Medicare and Medicare denied the claim. You also say that is why prior authorization was not obtained. The Plan denied your request. The Plan says there was no prior authorization obtained for non-emergent and non-participating services. The Plan also says that the services were provided by a non-participating skilled nursing facility and the services could have been provided by a participating skilled nursing facility.

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 occupational and physical therapy provided on September 7, 2021, to September 28, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational and physical therapy provided on October 5, 2021, to October 29, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for occupational and physical therapy. You say that you were unaware that the patient had a Medicare Replacement Plan and you billed Medicare and Medicare denied the claim. You also say that is why prior authorization was not obtained. The Plan denied your request. The Plan says there was no prior authorization obtained for non-emergent and non-participating services. The Plan also says that the services were provided by a non-participating skilled nursing facility and the services could have been provided by a participating skilled nursing facility.
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 occupational and physical therapy provided on October 5, 2021, to October 29, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a therapeutic continuous glucose monitor
(CGM) and supplies for the enrollee.
You asked the Plan to provide coverage for a therapeutic continuous glucose monitor (CGM) and
supplies for the enrollee. You say that a therapeutic continuous glucose monitor (CGM) and supplies is
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial for a lack of medical records in the case file. The Plan requested a reopen
and provided documentation to show the multiple attempts made to have your office submit medical records to
support the appeal.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic
CGMs are only covered when all the required coverage criteria are met. There are no exceptions. The Plan has
demonstrated that medical records were not submitted with the appeal to show the required criteria are met.
Therefore, we decided that the Plan does not have to provide coverage for a therapeutic continuous glucose
monitor (CGM) and supplies for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on August 30, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve image guided epidural injections (62321).

You asked the Plan to pre-approve the image guided epidural injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 image guided epidural injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that physical examination demonstrated sacral iliac findings. The record does not indicate the presence of thoracic level findings. A T10-T11 level injection is requested. The records do not support this service. 

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 image guided epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-approve image guided epidural injections (62321).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Colestipol tablets.

You asked the Plan to pre-approve Colestipol. You say that Colestipol is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.

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 Colestipol tablets.

Benefits for Colestipol may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.