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

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) provided on February 22, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this was not hospice related. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99307) and debridement (11721) 
provided on February 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care and debridement. You say that the enrollee has an 
authorization on file for all care at the facility. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
  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 nursing facility care (99307) and debridement 
(11721) provided on February 24, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 indwelling catheters. 
 
You asked the Plan to pre-approve 9 indwelling catheters. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no more than one catheter per month is covered for 
routine catheter maintenance. 
 
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 9 indwelling catheters. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found in this case, the record 
indicates that the enrollee has an indwelling suprapubic catheter. The records provided do not document the 
presence of at least one of the enumerated conditions for which coverage of more than one catheter a month is 
available. 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 9 indwelling catheters have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 9 indwelling catheters.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81286, 81413, 81414, 
81442, 81161 and 81479 provided December 9, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that please reconsider the denial for this enrollee. 
The Plan denied your request. The Plan says unable to verify provider's license. 
 
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. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services coded as 
81286, 81413, 81414, 81442, 81161 and 81479 provided December 9, 2021. have been met. The records show 
that the Plan made multiple attempts to obtain needed documentation from the provider without success. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded as 81286, 81413, 
81414, 81442, 81161 and 81479 provided December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tangential biopsy of skin (11103 & 11102) provided on 
September 24, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the skin biopsy. You say that the services were medically necessary The Plan 
denied your request. The Plan says the services were provided out-of-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 the tangential biopsy of skin (11103 & 11102) 
provided on September 24, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood testing (85025 & G0471) provided on March 1, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the blood testing. You say that these services were referred by the enrollee's 
physician. The Plan denied your request. The Plan says the referring physician and provider are out-of-network 
and were not approved in advance. 
  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 blood testing (85025 & G0471) provided on 
March 1, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for screening digital breast tomosynthesis/mammography (procedure code 
77063, 77067) provided to the enrollee on January 14, 2022. 
 
You asked the Plan to pay for the services. You say that this should bep aid for. The Plan denied your request. 
The Plan says that the incorrect place of service was used. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not specified why the place of service was inappropriate in this 
case. Our coding reviewer has found that the medical documentation does support the use of the denied 
procedure codes. There are no edits between 77063 and 77067, and 77067 is an add-on code that is customarily 
billed with primary code 77063. Therefore, we decided that the Plan has to pay for screening digital breast 
tomosynthesis/mammography (procedure code 77063, 77067) provided to the enrollee on January 14, 2022.  
 
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 pre-approve cryoablation of the peripheral nerves for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare does not cover procedures that are experimental or investigational, therefore, 
the requested procedure is not approved. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the role of cryoablation in knee osteoarthritis is still being considered and at this point, it is 
considered experimental and investigational. Therefore, the request is considered not medically reasonable or 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cryoablation of the peripheral nerves for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81216, 81413, 81414, 
81442, 81161 and 81479 provided December 21, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the lab does not require active medical/state 
license and your lab is operating within Texas. The Plan denied your request. The Plan says unable to verify 
provider's license. 
 
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. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services coded as 
81216, 81413, 81414, 81442, 81161 and 81479 provided December 21, 2021. have been met. The records show 
that the Plan made multiple attempts to obtain supporting medical records from the provider without success. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded as 81216, 81413, 
81414, 81442, 81161 and 81479 provided December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma panel provided on July 27, 2021. 
 
You asked the Plan to pay for the DecisionDx-Melanoma panel. You say that this is a Medicare-covered test 
that should be paid. The Plan denied your request. The Plan says the required Z-code was not reported, and the 
date of service is not supported. 
 
Medicare rules say that molecular diagnostic laboratory tests are subject to the MolDX application, assessment, 
and approval process. Once this is complete, the test is assigned a reimbursement rate and unique test identifier. 
 
We looked at the file and Medicare rules. The unique identifier was not included on the billed claim for this 
testing. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-Melanoma 
panel have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDx-
Melanoma panel provided on July 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a disposable ear mold insert (V5265) and a monaural 
hearing aid dispensing fee (V5241) provided on December 29, 2021. 
 
You asked the Plan to pay more for a disposable ear mold insert (V5265) and a monaural hearing aid 
dispensing fee (V5241). You say that based on the loss of the member's previous right hearing aid, this hearing 
aid was recommended. The Plan denied your request. The Plan says per the Plan benefit, the member is 
allowed $1,000 for hearing aids every four years. The Plan also says that the maximum benefit has been Maxed 
with the overturn of code V5247. 
 Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays up to 
$1,000 for hearing aids once every four years.  
 
We looked at the file and the Plan's rules. The record shows that the $1,000 benefit has been exhausted on 
December 29, 2021. Based on this information, we decided that the Plan's rules for coverage of a disposable ear 
mold insert (V5265), and a monaural hearing aid dispensing fee (V5241) have not been met. Therefore, we 
decided that the Plan does not have to pay more for a disposable ear mold insert (V5265) and a monaural 
hearing aid dispensing fee (V5241) provided on December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to waive the $75 copayment for diagnostic services.
You asked the Plan to reduce cost share. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was applied based on the services provided and the Plan contract agreement. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that the $75 copayment was the only copayment at issue in the appeal and Maximus agreed with the Plan regarding that copayment.
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 pay $75 for diagnostic services. You have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation. Therefore, we decided that the Plan does not have to reduce the copayment for diagnostic services provided on November 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a prosthetic hand coded as L7499 for the enrollee.
You asked the Plan to provide coverage for the requested code. You say that this prosthetic hand should be covered by the Plan. The Plan denied your request. The Plan says an untimely decision was made by the Plan and the case was forwarded to Maximus. Maximus administratively overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information.
The Plan explained that Medicare requires requests to be correctly coded per their guidelines and the provider must submit the correct codes for the prosthetic partial hand and finger prostheses. The Plan found that the code being reviewed did not correspond with the prosthetic the enrollee needed. It was found upon clinical review that the documentation does not support why a partial hand with no fingers remaining (L6020) did not meet the enrollees needs. On December 1, 2021, you were informed by the Plans clinical team that their medical director had reviewed code L7499 and was unable to approve the request due to insufficient information showing necessity for the enrollee.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the specific prosthetic hand requested for the enrollee have been met. Therefore, we decided that the Plan does not have to provide coverage for a prosthetic hand coded as L7499 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance for outpatient diagnostic services and supplies provided on December 20, 2021.
You asked the Plan to waive this coinsurance. You say that you do not believe this coinsurance is correct. The Plan denied your request. The Plan says this coinsurance was charged based on the services provided. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided an explanation of the decision and additional information.
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 20% coinsurance for outpatient diagnostic services and supplies. Based on the records provided, 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 20% coinsurance for outpatient diagnostic services and supplies provided on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for 7 additional visits.
You asked the Plan to pre-approve 13 visits. The Plan denied your request. The Plan says you had 12 visits prior. While 6 more visits were approved, 7 visits beyond that are not demonstrated to be medically necessary. Maximus overturned the Plans denial for a lack of medical records in the file. The Plan requested a reopen and provided the required medical records.
The Plan is correct in this case. 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. Maintenance is not covered. The records show the 12 prior visits and the 6 visits approved by the Plan should be sufficient to treat your condition. Anything beyond that is not demonstrated to be medically necessary. Therefore, we decided that the Plan does not have to provide coverage for the 7 remaining visits not approved.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for transfer handles, a power seat elevation system, an expandable controller, harness, and an electronic connection for a power wheelchair
You asked the Plan to provide coverage for any of these accessories and in particular the transfer handles. You say that these accessories are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus partially overturned the Plans denial by stating the transfer handles were found to be necessary and beneficial. The Plan requested a reopen and stated that the issue was not medical necessity but the fact that transfer handles are not covered by Medicare.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services with the appropriate codes. In this case the requested code is K0108 for Transfer Handles. These items do not serve a medical need and cannot be covered. Although these items are requested, no allowed amount is listed on the quote submitted. Based on this information, we decided that Medicare rules for coverage of any of these accessories and in particular the transfer handles have not been met. Therefore, we decided that the Plan does not have to provide coverage for transfer handles, a power seat elevation system, an expandable controller, harness, and an electronic connection for a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share charged for inpatient care provided from October 29, 2021, to October 30, 2021.
You asked the Plan to reduce this cost share. You say that you were only in the emergency room and not treated as an inpatient. The Plan denied your request. The Plan says the medical records show you were treated at an inpatient level of care. Maximus overturned the Plans denial for lack of confirmation you were treated as an inpatient. The Plan requested a reopen and provided the required information.
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 pay $350 a day for days 1 to 5 of an inpatient stay. The records show that you were treated at an inpatient level of care. It is possible for you to be in the emergency room and converted to inpatient status, which was the case here. 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 reduce the $350 copayment charged for inpatient care provided from October 29, 2021, to October 30, 2021.