Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services provided on April 6, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like this claim reprocessed. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plan's cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
payment. 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 pay more for the dental services provided on April 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven home health physical therapy (PT) visits and four 
occupational therapy (OT) visits. 
 You asked the Plan to pre-approve the requested home health services. You say that home health care is 
medically necessary for your condition. The Plan denied your request. The Plan says the criteria for additional 
home health services beyond what the Plan has already approved have not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 requested home health services. Our 
reviewer says that the requested home health services are not medically reasonable and necessary. Our 
physician reviewer found based on the documentation provided, the enrollee does not have documented home 
health skilled therapy needs. The enrollee is functioning at a level commiserate with a lower level of care. You 
currently live in a supervised setting with 24/7 caregiver availability. As such, the requested home health 
therapy services are not medically necessary or reasonable. 
 
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 requested home health services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve seven home health physical therapy (PT) visits and four 
occupational therapy (OT) visits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network outpatient mental health care provided from November 4, 2021, through December 4, 2021.
You asked the Plan to pay for out of network services provided to the enrollee. You say that you believe the services provided were medically necessary and should be covered by the Plan. The Plan denied your request. The Plan says the enrollee self-referred out of network for treatment without prior authorization.
The QIC upheld the Plans denial. You requested an ALJ hearing. It was determined in the ALJ hearing that the incorrect dates of service were provided by the Plan (October 21, 2021, to November 5, 2021). The ALJ remanded the case back to the QIC to determine the correct dates of service. The QIC solicited additional information from the Plan regarding the actual dates of service for the appeal. The Plan responded to the QIC and provided documentation to show the dates of service in question were supposed to have been November 4, 2021, through December 4, 2021.
After review of the new information from the Plan regarding the dates of service, we continue to uphold the Plans denial of payment for these services. 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 outpatient mental health care to the enrollee. The Plan did not pre-approve these services. The enrollee self-referred to the out of network provider without consulting the Plan for direction. The Plan contract is clear that out of network care is only permissible in certain circumstances or with Plan prior authorization. We continue to fine no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for out of network outpatient mental health care provided from November 4, 2021, through December 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rehabilitation therapy services billed for date of service 
January 17, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records prove medical necessity. The 
Plan denied your request. The Plan says the records do not show evidence of the procedures being performed. 
 
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 code 97012 is application of a modality to 1 or more areas; 
traction, mechanical. The definition of code 20999 is unlisted procedure, musculoskeletal system, general. 
 
We find that CPT codes 97012 and 20999 are not supported in the medical record. The records do not show 
that the services at issue were provided to the enrollee on the date of service at issue. 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 rehabilitation therapy services billed for date of service 
January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing 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. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan demonstrated that this claim denied because the service was billed inappropriately. The Plan states the provider has billed the appealed claim with Diagnosis Code 338.4 defined as chronic pain syndrome. The Plan states this diagnosis has been invalid since October 5, 2015. The Plan states the correct ICD-10 code for ICD description "chronic pain syndrome" is G89.4; according to the 2022 ICD-10-CM CMS General Equivalence Mappings (GEMS) information.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due to an error with the reported diagnosis code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on June 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377) electronic connection 
between wheelchair controller and two or more power seating system motors (E2311) harness for upgrade to 
expandable controller (E2313). 
 
You asked the Plan to pre-approve upgraded electronics. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested. The Plan denied your 
request. The Plan says the upgraded electronics are not medically necessary for the operation of the approved 
wheelchair. 
 
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 upgraded electronics. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require non-proportional input devices (e.g., sip and puff, head 
array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic 
devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an 
attendant control. The enrollee has 3 power options of tilt, recline, and power elevating leg rests but the patient 
does not need to control the power options through a joystick. The enrollee's left upper extremity strength and 
function support that the patient can control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve expandable controller (E2377) electronic connection between wheelchair 
controller and two or more power seating system motors (E2311) harness for upgrade to expandable controller 
(E2313).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the flex-walk system advanced foot prosthetic feature (L5981).

You asked the Plan to pre-approve the flex-walk system. You say that this prosthetic feature is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the documentation does not support the advanced foot feature requested.

The Plan follows Medicare rules. Medicare rules say that a flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 or above.

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 flex-walk system. Our reviewer says that the requested flex-walk system is not medically reasonable and necessary. Our physician reviewer found that you are a 60-year-old male with a medical history of diabetes mellitus type II, renal failure, peripheral artery disease and arthritis. The documentation provided does not support the use of the flex-walk (Ottobock Taleo foot) prosthetic foot. There is insufficient documentation regarding your potential K functional level. You have both a recent transtibial amputation and a history of a transmetatarsal amputation on his contralateral limb. There is no specific grading of motor strength or range of motion for each joint. There is insufficient documentation regarding your current functional status or an evaluation by physical therapy indicating your functional level. Therefore, the flex-walk (Ottobock Taleo foot) prosthetic foot is not 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 the flex-walk system have not been met. Therefore, we decided that the Plan does not have to pre-approve the flex-walk system advanced foot prosthetic feature (L5981).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the brain with 3D rendering.

You asked the Plan to pre-approve the 3D MRI of the brain. You say that this must be approved in order to diagnose Alzheimer's. The Plan denied your request. The Plan says that there is no medical need for 3D rendering of this imaging.

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 3D MRI of the brain. Our reviewer says that the requested 3D rending of the MRI of the brain is shown to be medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a female with cognitive decline. Her Mini Cog score varied between 1/5 and 4/5. The Mini-Mental State Examination could not be performed due to a language barrier. 

The 3D rendering requested as part of the MRI is medically necessary in patients suspected of having Alzheimer dementia (AD) such as this individual. The 3D rendering is necessary to measure hippocampal volume as explained in the letter of appeal. This measurement is crucial in the diagnosis of AD.

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 3D MRI of the brain have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the brain with 3D rendering. 

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 pay for removal of impacted cerumen using irrigation lavage
(69209) provided to the enrollee on August 13, 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 overturned the Plans denial stating
the services were shown to be necessary and two units of this service are allowed. The Plan requested a reopen
and states the issue was not the units, but how they were billed. The Plan shows this claim denied because the
service was billed with an inappropriate modifier. The Plan states the provider needed to bill the anatomic
specific modifiers LT (Left side), RT (Right side), and 50 (Bilateral procedure) designate the area or part of the
body on which the procedure is performed. The Plan provided the claim image that shows the provider has
billed this service without the appropriate modifier.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes and when necessary, the
appropriate modifier. In this case, this claim was not reported with the required anatomical modifiers.
Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does
not have to pay for removal of impacted cerumen using irrigation lavage (69209) provided to the enrollee on
August 13, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to provide coverage for a continuous glucose monitor (CGM) and sensor used with a Medtronic 670G model insulin pump.
You asked the Plan to provide coverage for this device. You say that this device is medically necessary. The Plan denied your request. The Plan says that Medicare coverage criteria are not met. Maximus upheld the Plans denial. After receiving new information from Medicare regarding coverage for this device, Maximus reopened the case and sent it for medical review.
Our Medical Director looked at the case file and the directions from Medicare. At issue is coverage for a continuous glucose monitor (CGM) sensor (A9276) used with a Medtronic 670G model insulin pump. The medical records show a diagnosis of Type 1 diabetes mellitus with hyperglycemia and a history of diabetic ketoacidosis. The Endocrinology note dated November 3, 2021, documents that the enrollee is on NovoLog via Medtronic 670G HCL since August 2018. She was on another system prior to that. It is documented that the enrollee had worked closely with the educator from Medtronic and felt it was very helpful to her understanding and management of the pump. The enrollee adjusted well to the 670G pump, and reported fewer glucose peaks and valleys, and overall, less hypoglycemia. The Plan denied coverage for the insulin pump, stating that the criteria were not met because "Medicare only covers therapeutic continuous glucose monitoring systems with an FDA approved non adjunctive indication and a Guardian Continuous Glucose Monitor is considered by Medicare to be a non-therapeutic Continuous Glucose Monitor." Medicare brought to our attention the new rule regarding CGMs stating non-therapeutic monitors can be covered if medically necessary. The documentation supports that the enrollee has diabetes, has received sufficient training on the use of her device, and that the CGM is medically reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this device have been met. Therefore, we decided that the Plan has to provide coverage for a continuous glucose monitor (CGM) and sensor used with a Medtronic 670G model insulin pump.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outside of the mouth X-rays (D0250). 
 
You asked the Plan to pay for the outside of the mouth X-rays. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this service is not covered 
under the Plan's supplemental benefit. 
 
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 the 
outside of the mouth X-rays (D0250).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $90 copayment charged for emergency room services
provided from October 29, 2021, to November 1, 2021.
You asked the Plan to waive this cost share. You say that you were admitted to the hospital and should not
have to pay this copayment. The Plan denied your request. The Plan says the claim shows you were listed an an
outpatient observation stay, not inpatient. Maximus overturned the Plans denial. The Plan requested a reopen
and stated that Maximus did not interpret the claim correctly.
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 $90 copayment for emergency room services.
This cost share is only waived if you are admitted to full inpatient status. The claim submitted and the records
show that while you did stay at the facility overnight, you were not considered an inpatient and all treatment
was provided as outpatient hospital 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 $90 copayment charged for emergency
room services provided from October 29, 2021, to November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture provided to the enrollee from May 21, 2020, to April 2, 2021.
You asked the Plan to pay for these services. You say that this treatment should be covered by the Plan. The Plan denied your request. The Plan says the provider was not eligible to bill Medicare and therefore is not eligible to provide treatment to Medicare covered enrollees.
The Plan must follow Medicare rules. Medicare requires acupuncture to be provided by a specific type of licensed profession. The provider in this case is a licensed acupuncturist but is not eligible to bill Medicare.
Therefore, we decided that the Plan does not have to pay for acupuncture provided to the enrollee from May 21, 2020, to April 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479) provided November 16, 2021.
You asked the Plan to pay for the genetic testing. You say that this service was 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 SelectMDx is covered for males with a previous
negative prostate biopsy who are being considered for a repeat biopsy.
We looked at the file and Medicare rules. The records do not show a previous negative prostate biopsy. Based
on this information, we decided that Medicare rules for coverage of the genetic testing have not been met.
Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs or medicaments dispensed in the office for home use 
(D9630) provided by a participating provider on March 24, 2022. 
 
You asked the Plan to pay for drugs or medicaments dispensed in the office for home use. You say that the 
dentist pulled the wrong tooth. You say that you feel like the Plan should have to pay for this. The Plan denied 
your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for drugs or 
medicaments dispensed in the office for home use (D9630) provided by a participating provider on March 24, 2022.