Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the arthrocentesis (20610), durable medical 
equipment (E1399), injection in tendon (20550), nerve blocks (64430, 64450), ultrasonic guidance (76942), 
and supplies and materials (99070) provided on July 21, 2022. 
 
You asked the Plan to reimburse you for the physician services. You say that the services you received were 
medically necessary. You also say that as a result of this denial, you are unable to properly maintain your 
physical health and wellness. The Plan denied your request. The Plan says the provider in this case has opted 
out of Medicare. The Plan also says that payment cannot be made for services that you received from a 
provider that has opted out of Medicare. 
 The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the arthrocentesis (20610), durable medical equipment (E1399), injection in tendon (20550), nerve blocks 
(64430, 64450), ultrasonic guidance (76942), and supplies and materials (99070) provided on July 21, 2022.
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 prior to admission the enrollee lived home alone, 
fully independent and was driving and needs aggressive rehabilitation at an IRF. The Plan denied your request. 
The Plan says the records do not show the need to be seen by a rehabilitation doctor at least three times a week 
for evaluation of functional and medical goals and progress. The services the enrollee needs may safely be 
provided safely in other settings. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the pelvis. 
 
You asked the Plan to pre-approve the MRI. You say that you need the test done so your doctor can see 
furthermore into the pelvis. The Plan denied your request. The Plan says there were no prior test findings; 
therefore, the MRI of the pelvis is not necessary at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
MRI of the pelvis is not medically necessary. Our physician reviewer found that the record indicates that the 
enrollee has hip and back pain. The record indicates that the enrollee had a lumbar MRI, but no results are 
provided. The record provided is insufficient to establish the medical necessity of the requested test. The 
requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's 
clinical condition at this time. The elements of the coverage criteria are not satisfied. 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the pelvis.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 19, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 70450 is a column II code to column I code 70496. The code at issue 
has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
70450 billed for date of service July 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a PET scan for the initial staging of prostate cancer for the enrollee.
You asked the Plan to provide coverage for a PET scan. You say that at the time of the appeal this PET scan was medically necessary. The Plan denied your request. The Plan says a PET scan is not covered for the initial staging prostate cancer. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct Medicare criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not cover PET scans for the initial staging of prostate cancer. Therefore, we decided that the Plan does not have to provide coverage for a PET scan requested for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ferric carboxymaltose injection provided on May 14, 2022.
You asked the Plan to waive the coinsurance for the ferric carboxymaltose injection. You say that you cannot afford to pay this. The Plan denied your request. The Plan says this cost sharing was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B drugs. You have been asked to pay a 20% coinsurance for the ferric carboxymaltose injection. This item/service falls within the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the ferric carboxymaltose injection provided on May 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
The Plan is correct in this case. 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. Based on the medical records provided, the enrollee did not require the level of rehabilitation provided as an inpatient at an IRF. The issues the enrollee needed assistance with were custodial in nature such as dressing or showering, which are not reasons for IRF approval. Medicare coverage criteria were not met.
Therefore, we decided that the Plan does not have to provide coverage for inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the $550 copayment charged for inpatient care provided from May 12, 2022, to May 24, 2022.
You asked the Plan to waive this copayment. You say that you do not believe this cost share is billed correctly. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans denial stating this was outpatient observation. The Plan requested a reopen and stated that Maximus did not apply the correct contract criteria. The Plan confirmed this was inpatient care and the cost share was applicable. You were admitted to inpatient status on May 12, 2022, and discharged on May 25, 2022. The inpatient cost share applied was $275 for two days as inpatient copayments had previously applied due the same benefit period. While it is understood you signed an observation admission document, you were converted to inpatient status by the provider.
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). Your contract with the Plan clearly says that you must pay a cost share inpatient care. 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 $550 copayment charged for inpatient care provided from May 12, 2022, to May 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the intensity modulated radiation treatment delivery (IMRT) provided to the enrollee on May 4, 2022, by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan denied your request. The Plan says that services from non-participating providers are not covered unless they are pre-authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 the intensity modulated radiation treatment delivery (IMRT) provided to the enrollee on May 4, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided from March 6, 2021, to August 2, 2021.
You asked the Plan to pay for these services. You say that all these services were medically necessary and should be covered. The Plan denied your request. The Plan says at the time of the appeal, the documentation required to show these services were necessary out of the country was not provided. Maximus overturned the Plans denial. The Plan requested a reopen and stated that additional information was discovered after our decision.
The Plan notes that for calendar year 2021, you were enrolled as a member of this Plan which has a service area limited. In February 2021, you received a magnetic resonance imaging (MRI), which together with subsequent tests also obtained, showed you had both bladder and prostate cancer. Your condition was stable. Between March 6, 2021, and August 2, 2021, you had radiation therapy, scans, received medications and other services in connection with this new cancer diagnoses, all while residing. At no point during his treatment did you contact the Plan to advise of your condition or to seek authorization for these services. Your last visit with your Plans primary care physician was on September 10, 2019. You did not advise the Plan that you moved. It was only after the Plan denied your out of country treatments that you disclosed you were living on and off for the last several years and that you are now permanently.
Both Medicare and your Plan requires its members to reside in the United States and for this Plan in the service area. You must disenroll from the Plan if you leave the service area. You submitted claims totaling $20,173.83 for the services received. These services were not authorized and are not considered urgent or emergent as your condition was identified, you were stable, and the treatments received were ongoing. It has also been established that you were living outside the service area as well as the country at least six months prior to the treatments provided.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. Based on the information provided with reopen, you did not follow your Plan rules in obtaining these services. Once your diagnoses and condition were stable, you could have been treated in the United States. You also neglected to tell the Plan that, for the most part, you had physically moved out of the Plans service area as well as out of the country. Medicare rules for coverage of these services were not met. Therefore, we decided that the Plan does not have to pay for medical services provided from March 6, 2021, to August 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary. The Plan denied your request. The Plan says at the time of the appeal Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. 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. The medical records provided do not show that at the time of the appeal, the enrollee had or would be expected to have the physical ability to participate in or at that time benefit from a rehabilitative program to include at least three hours of therapy per day at least five days per week. Whether or not the admission might be beneficial for the enrollee, the medical records do not show that the
Medicare rules for coverage of IRF care were met at the time the appeal was initiated. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor billed for date of service 
August 5, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed 
modifier is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We find that CPT code K0553 was billed with a KX modifier. The medical records do not show that the 
enrollee is being treated with insulin. Based on this information, we decided that Medicare rules for coverage 
of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for the 
continuous glucose monitor billed for date of service August 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Koya Dayspring non-pneumatic compression system 
(K1024, K1033). 
 
You asked the Plan to pre-approve a Koya Dayspring non-pneumatic compression system. You say that the 
requested items are a medical necessity for you. The Plan denied your request. The Plan says the requested 
items are experimental/investigational. 
 
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 a Koya Dayspring non-pneumatic 
compression system. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that all the available documentation has the same 
language in terms of you trying a basic pump. It is not clear when you attempted this and what type of 
compression device was utilized. Additionally, there is no documentation that you have attempted standard 
lymphedema treatment with a therapist. There is no documentation indicating a lack of failure to respond to a 
standard compressive device in terms of objective measurements. There also needs to be objective 
documentation that you have responded to the requested device with a trial.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Koya Dayspring non-pneumatic compression system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Koya Dayspring non-pneumatic 
compression system (K1024, K1033).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS heart failure system (33289 and 
C2624). 
 
You asked the Plan to pre-approve the system. You say that the system is medically necessary. The Plan denied 
your request. The Plan says the CardioMEMS device is considered unproven and is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the system. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the CardioMEMS system would not be considered medically appropriate and necessary in this 
enrollees clinical management. 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 system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the CardioMEMS heart failure system (33289 and C2624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 3, 2022. 
 
You asked the Plan to pay for the billed services. You say that the code is billable and valid. The Plan denied 
your request. The Plan says the diagnosis code requires a fifth digit to be billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 We find that CPT code 99212 was billed with diagnosis code M54.5. A code is considered invalid if it has not 
been coded to the full number of characters required for the code. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on May 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart permanent cardiac contractility 
modulation (CCM) system. 
 
You asked the Plan to pre-approve CCM system. You say that the enrollee failed conservative treatment. The 
Plan denied your request. The Plan says this procedure is experimental/investigational. 
 
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 CCM system. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found CCM remains the subject of multiple studies examining long-term efficacy as well as 
randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CCM system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Optimizer Smart permanent cardiac contractility modulation (CCM) system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99442 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code 99442. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
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 99442 is 1. The MAI value for this code is 2. We find that 2 units of code 
99442 were billed on the same date, by the same billing provider, exceeding the MUE. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99442 billed for date of service July 26, 2022.