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

 
We decided that the Plan does not have to pay for lab services (81286, 81413, 81414, 81442, 81161, 81479) 
provided December 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the 
physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the 
results in the management of the beneficiary's specific medical problem.  
 
 
 We looked at the file and Medicare rules. The records show this test was not ordered by the enrollee's primary 
physician. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (81286, 81413, 81414, 
81442, 81161, 81479) provided December 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 4, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the medical records support payment for this 
code. 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. 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 procedure code 70450 billed for date of service November 4, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service November 4, 
2021. 
 
You asked the Plan to pay for procedure code 74018. You say that this claim was coded correctly. The Plan 
denied your request. The Plan says payment for code 74018 is bundled into payment for code 74240.  
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 74018 
is a column II code to column I code 74240. 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 procedure code 74018 billed for date of service November 4, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with codes A6531, 
A6532, and A6545.  
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for 
coverage of the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531, 
A6532, A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also 
say that compression bandages and gradient compression wraps are covered only when they are used as 
dressings over a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with codes 
A6531, A6532, and A6545.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 12, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says out-of-
network services are not covered under your Plan. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit provided on March 24, 
2022. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that this was just a phone call from 
the doctors office to verify that the surgery was cancelled. 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 $40 
copayment for each telehealth specialist visit.  
 
You have been asked to pay a $40 copayment for the telehealth visit. The telehealth visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the telehealth visit provided on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician's services provided from 
May 27, 2021, to November 9, 2021. 
 
You asked the Plan to waive the copayment for physician's services. The Plan denied your request. The Plan 
says the claims processed 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 $40 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for physician's services. The physician's services falls within the 
Physician/Practitioner services, including doctors office visits 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 physician's services provided from May 27, 2021, to November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift (E1399). 
 
You asked the Plan to pre-approve a stair lift. You say that the stair lift is medically necessary due to the 
enrollee's Parkinson's disease. The Plan denied your request. The Plan says a stair lift is not a covered item. The 
stair lift is considered a convenience item that is not primarily medical in nature. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 11, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. 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 it was determined 
these services can be received in-network. 
 
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 laboratory services provided on March 11, 2022, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee cannot take bisphosphonates. The Plan 
denied your request. The Plan says step therapy requirements have not been 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 Prolia. Our reviewer says that the 
requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial 
of bisphosphonates by mouth and by injection before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drugs. There is no indication that the Plans required drugs would 
likely be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the $350 copayment charged for inpatient care provided from May 5, 2021, to May 6, 2021.
You asked the Plan to waive or reduce this copayment. You say that you were not admitted to the hospital and this copayment is not correct. The Plan denied your request. The Plan says this cost share was charged based on the claim submitted by your provider and the Plan contract agreement. Maximus overturned the Plans denial for a lack of documentation in the case file to show you were admitted. The Plan requested a reopen and provided documentation to show that your status was changed from emergency room care to inpatient care during the course of your treatment.
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 $350 copayment for inpatient care.
The documentation shows that you were admitted to an inpatient level of care during your course of treatment. Whether or not you left the emergency room or changed clothing is not of issue. The Plan has demonstrated the level at which you were being monitored as at an inpatient level of care due to the possibility of the condition becoming more serious.
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 or reduce the $350 copayment charged for inpatient care provided from May 5, 2021, to May 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical removal of forehead wrinkles. 
 
You asked the Plan to pre-approve the surgical removal of forehead wrinkles. You say that the requested 
surgical removal of forehead wrinkles is medically necessary. The Plan denied your request. The Plan says the 
requested surgical removal of forehead wrinkles 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 surgical removal of forehead 
wrinkles. Our reviewer says that the requested surgical removal of forehead wrinkles is not medically 
necessary. Our physician reviewer found the record indicates that the enrollee has been approved for brow 
ptosis surgery. The additional requested procedure will not improve a functional deficit and is cosmetic in 
nature. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested 
service is not recommended. 
 
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 surgical removal of forehead wrinkles have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the surgical removal of forehead wrinkles.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that at the time of the appeal, SNF care was medically necessary. The Plan denied your request. The Plan says care was no longer required at an inpatient level of SNF care. Maximus administratively overturned the appeal because the case file lacked an appropriate notice of non-coverage. The Plan requested a reopen and provided that documentation.
The Plan is correct in this case. 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. Based on the medical records provided, as of March 19, 2022, you no longer met the criteria required to receive continued care in a SNF facility. The records do not show you required daily skilled nursing or daily skilled therapy services at an inpatient level of care. Medicare rules for coverage of SNF care were not met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller and accessories (E2377, E2313, E2311). 
 
You asked the Plan to pre-approve an expandable controller and accessories. You say that this is medically 
necessary for your condition. The Plan denied your request. The Plan says that the requested expandable 
controller and related accessories are not necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to the criteria 
listed 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 an expandable controller and 
accessories. Our reviewer says that the requested expandable controller is medically reasonable and necessary. 
Our physician reviewer found that you are a 54-year-old male with a medical history cerebral palsy, chronic 
right shoulder pain, lymphedema, and asthma. You are modified independent with bathing, dressing, toileting, 
grooming and eating. You are noted to have adequate motor strength in the upper extremities to operate a 
standard joystick and switches for power wheelchair components, such as power tilt and recline and power 
elevating leg rest. While the patient could operate these options independently, a non-expandable controller 
would not allow the patient to operate all the components simultaneously and in a proportional manner, when attempting to maneuver the power wheelchair and position it efficiently when performing activities of daily 
living, such as bathing, dressing and hygiene care. Therefore, the expandable controller is 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 an expandable controller and accessories have been met. Therefore, we decided 
that the Plan has to pre-approve an expandable controller and accessories (E2377, E2313, E2311).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2752) and core buildup (D2950) for tooth #30 
provided on May 10, 2022. 
 
You asked the Plan to pay for a crown and core buildup. You say that you believe these services should be 
covered by your dental benefits. The Plan denied your request. The Plan says the denial for these services is 
correct, because crowns and core buildup are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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. Therefore, we decided that the Plan does not have to pay for a crown 
(D2752) and core buildup (D2950) for tooth #30 provided on May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311), a seat 
elevation system (E2300), item hook (K0108), and cushion foam (K0108). 
 
You asked the Plan to pre-approve an expandable controller, a seat elevation system, item hook, and cushion 
foam. You say that these items are medically necessary. The Plan denied your request. The Plan says you can 
control the approved power options through their own switches and the other items are not medical in nature. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered if it is medically 
necessary for any of the functions listed in the rules section. A power seat elevation feature (E2300) is non-
covered because it is not primarily medical in nature. Medicare will pay for durable medical equipment that is 
mainly used to serve a medical purpose.  
 
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 an expandable controller, a seat 
elevation system, item hook, and cushion foam. Our reviewer says that the requested items are not necessary. 
Our physician reviewer found the expandable controller is not medically necessary as you have use of the 
upper extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. The seat elevation system, item hook, and cushion foam are not medical in nature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, a seat elevation system, item hook, and cushion foam 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller 
(E2377, E2313, E2311), a seat elevation system (E2300), item hook (K0108), and cushion foam (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins (D2950) provided from 
April 20, 2022, to April 26, 2022. 
 
You asked the Plan to pay for the core buildup. You say that the Plan should cover the services at the in-
network rate. The Plan denied your request. The Plan says they will allow additional payment for the covered 
services at the in-network rate but will not provide payment for the non-covered service. 
 
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. Therefore, we decided that the Plan does not have to pay for core 
buildup, including any pins (D2950) provided from April 20, 2022, to April 26, 2022.