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

We decided that the Plan does not have to pay for dental x-rays (D0210) provided on April 18, 2022.
You asked the Plan to pay for these dental services. You say that these x-rays should be covered by the Plan. The Plan denied your request. The Plan says your benefit for the x-rays was not available at the time of service.
The Plan is correct in this case. 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, certain limitations apply. The record shows your benefit for x-rays was not available until July 29, 2022. You exhausted this benefit on July 28, 2021. Therefore, we decided that the Plan does not have to pay for dental x-rays (D0210) provided on April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the $195 copayment for a crown on tooth #31 (D2751) provided on March 18, 2022.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans denial for insufficient contract information in the case file. The Plan requested a reopen and provided the required documentation.
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 $195 copayment for dental crowns. 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 $195 copayment for a crown on tooth #31 (D2751) provided on March 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplicate mammography screening billed twice provided to the enrollee on October 21, 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. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan notes that the Medicare billing guidelines show codes 77067 and 77063 should be used for billing a screening mammogram in addition to tomosynthesis. The records show a screening bilateral mammography and digital breast tomosynthesis on October 21, 2021. Comparison shows the additional report provided is a duplicate copy of the services provided.
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, it appears the claim was submitted for payment twice with two identical reports. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for a duplicate mammography screening provided to the enrollee on October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for a home air conditioning unit purchased December 29, 2021.
You asked the Plan to pay for a home air conditioning unit. You say that this air conditioner should be covered by the Plan. The Plan denied your request. The Plan says the records provided do not show you met the criteria required for payment of this equipment. Maximus overturned the Plans denial for a lack of medical records in the file. The Plan requested a reopen and provided records to show you were not enrolled in the required respiratory program for 2021 or 2022.
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. Your contract with the Plan clearly says that you must be enrolled in a specific respiratory program for an air conditioner to be covered. The medical records provided do not show enrollment in the required program. Therefore, we decided that the Plan does not have to pay for the home air conditioning unit (99199) purchased December 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from November 3, 2019, to January 3, 2020.
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 claim submission and documentation was incomplete. Maximus overturned the Plans denial. The Plan requested a reopen and provided documentation to show they requested all medical records and itemized claim information on multiple occasions. The records do not show those requests were responded to.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
There is insufficient documentation in the record to determine if Medicare rules for coverage of these services have been met. The Plan provided documentation to show they requested the required information several times. Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee from November 3, 2019, to January 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 1, 2022.
You asked the Plan to pay for these services. You say that this testing should be covered by the Plan. 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 criteria. The Plan notes that the required unique test identifier or DEX Z-Code was not submitted on the claim. The claim was billed with a place of service (POS) 81, for an independent laboratory taking the sample. However, the medical records show the sample was collected in the provider's facility. There is no documentation that the sample was taken by the laboratory directly. The claim was also billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that a specimen was collected on February 11, 2022. There is no documentation of molecular pathology testing performed on the date billed of March 1, 2022, with a POS 81.
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, this claim could not be paid due to errors with the POS code reported, the dates of service reported and the omission of a required test identifier code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 8, 2022.
You asked the Plan to pay for these services. You say that this testing should be covered by the Plan. 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 criteria. The Plan noted that the claim was submitted with the incorrect POS code of 81, indicated the independent laboratory collected the specimen, however the medical records show the specimen was collected in the hospital. The claim was also submitted without the required unique test identifier or DEX Z-code.
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 the claim could not be paid due to the reporting of an incorrect POS code and the omission of the required test identifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 8, 2022.
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.
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 Medicare coverage criteria were not met.
Maximus overturned the Plans denial stating IRF care would be beneficial. 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
rules are clear that you must meet specific criteria prior to admission for IRF care to be covered. Whether or
not the care would be beneficial is not an appropriate review, the records clearly show that at the time of the
appeal prior to admission you did not meet all the criteria required by Medicare for coverage.
Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility
(IRF) admission and services.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that a lower level of care and skilled nursing facility
cannot provide a total interdisciplinary approach needed. The Plan denied your request. The Plan says that
based on Medicare guidelines and the information they have about the enrollee's condition she does not meet
the requirements for approval. Maximus overturned the Plans denial stating IRF care would be necessary. 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
rules are clear that you must meet specific criteria prior to admission for IRF care to be covered.
The medical records do not clearly show that at the time of the appeal the enrollee required treatment by a
rehabilitation physician three days per week nor did the enrollee require three hours of therapy five days per
week. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility
(IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 11, 2022.
You asked the Plan to pay for this testing. You say that this claim should be paid by the Plan. 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 provided additional information. The Plan notes that this is an administrative determination for billing and is not based on clinical criteria for medical necessity. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service. The specimen was collected during a hospital outpatient encounter. Further, the test has not been cleared or approved by the FDA and is not a companion diagnostic for any therapy
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, this claim could not be paid as billed due to an incorrect POS code and a lack of medical records to show the testing was medically necessary. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 4, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. 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 provided additional information. The Plan notes that this is an administrative determination for billing and is not based on clinical criteria for medical necessity. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service. The specimen was collected during a hospital outpatient encounter, therefore the POS code reported is incorrect. In addition, the claim was submitted without the unique test identifier or DEX Z-Code required by Medicare for this type of test.
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, this claim could not be paid due to an inappropriate POS code and the omission of the required test identifier code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan for the enrollee
You asked the Plan to pre-approve a CT scan. You say that the CT scan is necessary. The Plan denied your
request. The Plan says that a CT scan is not necessary with a standard total knee arthroplasty.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary. Maximus overturned the Plan's denial stating the CT scan would be necessary. The Plan
requested a reopen and stated that Maximus applied the incorrect criteria.
We looked at the file and Medicare rules. This CT was requested for a procedure that was not approved by the
Plan. Based on this information, we decided that Medicare rules for coverage of a CT scan have not been met.
Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan for the
enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for magnetic resonance imaging provided to the enrollee on June 23, 2022
You asked the Plan to pay this claim. The Plan denied your request. The Plan says that this service was
investigational. The Plan also stated their time to review this service had expired and the case was forwarded to
Maximus. After supervisor review the case was reopened, as it was determined the Plan did not present an
appropriate case file.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. The case file submitted by the Plan consisted of 28 pages with no clear explanation of the decision.
While we understand the Plans time to review the case expired, the Plan is still required to submit an
appropriate case to the IRE. The Plan has not made reasonable and diligent efforts to gather and forward to us
information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for
magnetic resonance imaging provided to the enrollee on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide full coverage for dental services to include an autogenous connective tissue graft procedure (D4273), intravenous moderate sedation (D9243, D9239), and other drugs/medicaments (D9630).
You asked the Plan to cover these the dental services. The Plan denied your request. The Plan says the maximum dental benefit for 2022 was $2000 and that the projected cost for these services exceeds this. Maximus partially overturned the Plans denial for insufficient information in the case file of the prior benefits used. The Plan requested a reopen and provided a break down to the dental services paid prior to this appeal.
The Plan is correct in this case. 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.
The Plan covered up to $2000 for 2022.
The record shows for date of service May 9, 2022, the Plan paid $1,138.00, for date of service May 19, 2022, the Plan paid $181.00 and for date of service June 30, 2022, the Plan paid $136.00 of the $2000 maximum benefit. This left $545.00 remaining to be paid towards the requested services. Any amount over the $2000.00 would be your financial responsibility. Therefore, we decided that the Plan does not have to provide full coverage for dental services to include an autogenous connective tissue graft procedure (D4273), intravenous moderate sedation (D9243, D9239), and other drugs/medicaments (D9630).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) of the right knee for the enrollee.

You asked the Plan to pre-approve a CT scan. You say that this is medically necessary. The Plan denied your request. The Plan says that medical studies do not support the use of a computed tomography (CT) scan to plan for knee replacement surgery, unless the x-rays show certain abnormal findings.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. Maximus overturned the Plan's denial stating the CT scan would be necessary. The Plan requested a reopen and stated that Maximus applied the incorrect criteria.

We looked at the file and Medicare rules. This CT was requested for a procedure that was not approved by the Plan. Based on this information, we decided that Medicare rules for coverage of a CT have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) of the right knee for the enrollee.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that at the time of the appeal, these services were medically necessary for the enrollee. 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 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. While the records indicate an IRF admission would have been beneficial and that the enrollee did not have adequate care during the day at home, the records do not indicate an ability to participate in at least three hours of therapy per day at least five days per week.
Medicare rules for coverage of IRF care were not met at the time of the appeal. Therefore, we decided that the Plan does not have to pre-approve acute 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the criteria and needs to back to his prior level of function. The Plan denied your request. The Plan says that based on Medicare guidelines and the information received about the enrollee's condition, the enrollee does not meet the requirements. Maximus overturned the Plans denial stating IRF care would be necessary. 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 rules are clear that you must meet specific criteria prior to admission for IRF care to be covered.
Based on the medical records provided at the time of the appeal, it was not expected that the enrollee would be able to participate in an intensive rehabilitation therapy to include three hours of full participation per day for five days per week. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 4, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. 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 provided additional information. The Plan notes that this is an administrative determination for billing and is not based on clinical criteria for medical necessity. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. This code indicates an independent laboratory took the sample. However, the medical records show the specimen was collected during a hospital outpatient encounter and not by the independent laboratory. In addition, the test has not been cleared or approved by the FDA and is not a companion diagnostic for any therapy.
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, this claim was billed with an incorrect POS code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 4, 2022.