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

 
We decided that the Plan does not have to pre-approve Promethazine. 
 
You asked the Plan to pre-approve Promethazine. The Plan denied your request. The Plan says oral, self-
administered drugs are covered by the pharmacy 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 Promethazine.  
 
 
 Benefits for Promethazine 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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services provided to the enrollee on November 27, 2021. 
 
You asked the Plan to pay for the services. You say that insurance coverage should have been provided during 
this emergency. The Plan denied your request. The Plan says that this diagnosis is not expected for this type of 
service. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
A prudent layperson would have believed without medical attention, there would have been serious danger to 
your health. Uncontrolled vomiting and diarrhea are reasonable emergent symptoms that were reported on the 
claim. You had no control over how the claim would be billed. Additionally, the plan did not substantiate their 
denial, as no medical records were provided to clarify some of the symptoms and treatment.  Based on this 
information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided 
that the Plan has to pay for ambulance services provided to the enrollee on November 27, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a back injection performed on February 10, 
2022. 
 
You asked the Plan to waive the copayment for the injection. You say that you cannot afford the copayment 
and the injection did not help. 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 $100 
copayment for outpatient procedures and services that are not colonoscopies.  
 
You have been asked to pay a $100 copayment for the injection. The injection falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities 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 back injection performed on February 10, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has right knee pain due to 
unilateral primary osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc or Supartz 
FX. The records do not show that the required drugs would be contraindicated or less effective; therefore, 
Gelsyn-3 is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gelsyn-3.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that at the time of the appeal, SNF services were
medically necessary. The Plan denied your request. The Plan says 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.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services.
The Maximus Physician Reviewer determined that you were functioning below baseline and had documented
skilled therapy needs. The Plan requested a reopen and argues that you had been unable to progress after 4
weeks of inpatient skilled therapy. The Plan states that both physical and occupational therapy evaluations
recommended discharge to 24-hour supervision and assistance, but not to a SNF. The Plan also states that
neither PT nor OT asserted that skilled services were required to establish a maintenance program and/or
prevent deterioration your condition.
The medical records show you have an extensive health history; however, the Plan is correct in this case. The
medical record documentation does not support that it was medically reasonable and necessary to provide
skilled services daily on an inpatient basis in a SNF. We looked at this physician's review, the file, and
Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have
not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF)
services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapy (97012), electric stimulation 
therapy (97014), ultrasound therapy (97035), and the massage therapy (97124) provided on July 23, 2019. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services at issue in this case are not a 
covered benefit under your contractual policy or by Medicare. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the mechanical traction therapy (97012), electric stimulation therapy 
(97014), ultrasound therapy (97035), and the massage therapy (97124) provided on July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for these services
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct billing guidelines. The Plans states
that a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between codes
36620 and 99221. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI
are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit
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 code and when required the
appropriate modifier. 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 these services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the therapeutic exercises (97110) and the 
manual therapy techniques (97140) provided from December 15, 2021, through December 27, 2021. 
 
You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the deductible was applied correctly to the 
services provided. 
 
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 $750 yearly deductible. This is the amount you 
have to pay out-of-pocket before the Plan will pay their share for your covered medical services. Until you 
have paid the deductible amount, you must pay the full cost of your covered services. Once you have paid your 
deductible, the Plan will begin to pay their share of the costs for covered medical services and you will pay 
your share (your copayment or coinsurance amount) for the rest of the calendar year. Additionally, there is a $0 
copayment after the deductible is met for each therapy visit.  
 
You have been asked to pay $369.65 for the physical therapy services provided as you had not previously met 
the yearly deductible. This is the Plans allowed amount for the services provided in this case. 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 deductible for the therapeutic exercises (97110) and the manual therapy techniques 
(97140) provided from December 15, 2021, through December 27, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for intensity modulated radiation therapy (IMRT) provided to the enrollee 
on December 29, 2021. 
 
You asked the Plan to pay for the therapy. You say that this should be paid for. The Plan denied your request. 
The Plan says that Medicare guidelines require radiation to be delivered by conventional means unless 
otherwise justified. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the therapy. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that intensity modulated radiation therapy (IMRT) is a technique used to improve dose conformality. The 
use of IMRT for the treatment of breast cancer is becoming more widely used.  In general, IMRT is not an 
experimental technique, but rather a radiation planning and delivery tool available to the radiation oncologist to 
better shape the radiation dose distribution, and therefore minimize the dose to normal structures. There is no 
actual plan comparison showing that above constraints could not be met with non-IMRT based planning. 
However, with regional nodal/IMN radiation it is highly plausible that IMRT is needed to minimize lung and 
heart exposure. In summary, it is safe to say that IMRT is not experimental, but rather a useful tool available to 
radiation oncologists to potentially reduce toxicity and improve the dose distribution in select patients when the 
dose-volume exposure of the heart and lungs warrant its use.  For this patient, with a complex treatment field 
the improvement in the IMRT vs. standard plan with respect to lung and heart dose exposure is plausible. 
 
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 therapy have been met. Therefore, we decided that the Plan has to pay for 
intensity modulated radiation therapy (IMRT) provided to the enrollee on December 29, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) provided on November 
10, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 magnetic resonance imaging (MRI) provided on 
November 10, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 10, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans
denial. The Plan requested a reopen and provided additional claim information. The Plan says that codes
95938, 95957, 95908, 95937, 95887 and 95885 received were denied for records requested were not received
on July 29, 2021. Records were received and these codes were reprocessed. Procedure code 95938 was
processed and paid. Procedure codes 95957, 95908, 95937, 95887 and 95885 were denied. A Provider
Remittance Advice was sent to the provider with appeal rights. A copy of that Provider Remittance Advice has
been attached with the reopen.
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, we have previously confirmed that code G0453 is a column II code to
column I code 95957. This claim 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 continuous intraoperative neurophysiology monitoring (G0453).
In addition, it has been confirmed that code 95938 was processed and paid and codes 95957, 95908, 95937,
95887 and 95885 were denied and given further appeal rights. If they Plan continues to deny those codes on
appeal, that matter will be forwarded to Maximus for review under a new case number. Therefore, we decided
that the Plan does not have to pay for lab services provided to the enrollee on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for a specialist office visit and 
aflibercept injection provided on January 27, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for the office visit and injection. You say that you 
never had to pay for this service before. The Plan denied your request. The Plan says the correct copayment and 
coinsurance were applied. 
 
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 $40 
copayment for each specialist visit. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs. 
 You have been asked to pay a $40 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to 
pay $732.60, which is 20% of the allowed amount for the injection ($3,663.00 allowed amount x 20% 
coinsurance = $732.60). The injection falls within the Medicare Part B Prescription Drugs benefit category. 
The total for the visit is $772.60. 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 and coinsurance for a 
specialist office visit and aflibercept injection provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on February 2, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that it is the legal responsibility of the 
insurer to pay medical claims for medically necessary procedures, whether there is an authorization in place or 
not. The Plan denied your request. The Plan says services from non-participating providers are not covered 
unless preauthorized. 
 
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 domiciliary or rest home visit provided on 
February 2, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for dentures.
You asked the Plan to provide coverage for dentures. You say that dentures were necessary. The Plan denied
your request. The Plan says the requested dental services are not covered. Maximus overturned the Plans
denial. The Plan requested a reopen and provided additional information. The Plan has confirmed that you did
not sign up for the supplemental dental benefit insurance for 2022.
The Plan is correct in this case. Medicare does not cover dentures. The Plan only covered dentures for enrollees
who purchase and pay for the supplental dental premium. The records show you did not purchase the
supplement dental benefit offered by the Plan. Therefore, we decided that the Plan does not have to provide
coverage for dentures.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on April 1, 2021. 
 
You asked the Plan to pay for . You say that this should be paid for. The Plan denied your request. The Plan 
says the records submitted do not indicate that two separate services were performed or supported. 
 
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, the CPT Code Manual definition of the denied codes is: 
 
CPT 36556: 
 
Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older 
 
CPT 36620: 
 
Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); 
percutaneous 
 
We asked our coder 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 . Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that based on the medical documentation, the 
procedure described does not fully indicate that CPT 36556 or CPT 36620 were rendered in this case. The 
documentation does not fully support the procedure codes billed. The provider needed to be more detailed to 
capture the exact procedure codes. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of  have not been met. Therefore, we decided that the Plan does not have to pay for 
surgical services provided to the enrollee on April 1, 2021.