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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 criteria.
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, you did not require daily skilled nursing or daily skilled therapy services at an inpatient level of your case. The records show your needs were custodial in nature, which is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 9, 2022.
You asked the Plan to pay for this testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional clarification. The Plan demonstrated that an independent laboratory taking a sample in its laboratory shows "81" as place of service. The medical records show the specimen was collected and sent directly to the lab on April 9, 2022, via a buccal swab as of the actual date of service. As the sample was not taken onsite in the billing laboratory, a place of service code of 81 is incorrect.
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 issue with the POS code. 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 9, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from
November 16, 2021, to November 30, 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 for
insufficient claim information. The Plan requested a reopen and provided additional information. The Plan
noted that they were unable to validate the enrollee had a Mechanically altered diet while in facility. The
enrollee was to be given nothing by mouth and receives enteral feedings. Documentation does not support a
mechanically altered diet.
The HIPPS code was reduced on the initial review because per the CMS RAI Manual Chapter 3 MDS item K;
Nutritional approaches: K0510. Pgs. K10-K12 stating Enteral feedings are not to be coded as mechanically
altered diets. (See attachment). The facility coded both a swallowing problem and a mechanically altered
diet (SLP category K) but should have only coded the swallowing problem (resulting in SLP category L).
The mechanically altered diet cannot be supported with the enteral feedings per CMS RAI Manual. The
decision to uphold the change from Billed HIPPS code of MLEE1 to MKEE1 is correct.
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 errors with the HIPPS code reported. Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility
services provided to the enrollee from November 16, 2021, to November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abutment supported porcelain (D6060) for tooth number 14, an implant placement (D6010) for tooth number 14, a prefabricated abutment (D6056) for tooth number 14, a bone replacement graft for ridge preservation (D7953) for tooth number 14, sinus augmentation (D7951) and a computed tomography (CT) scan (D0367).
You asked the Plan to pre-approve the dental services. You say that you have tooth pain and cannot eat. The Plan denied your request. The Plan says that your benefit for the cone beam computed tomography (CT) capture has already been exhausted and that an abutment supported porcelain, an implant placement, a prefabricated abutment, a bone replacement graft for ridge preservation and sinus augmentation are not covered.
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 the computed tomography (CT) scan was exhausted on date of service August 18, 2022.
The requested abutment supported porcelain, implant placement, prefabricated abutment, bone replacement graft for ridge preservation and sinus augmentation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an abutment supported porcelain (D6060) for tooth number 14, an implant placement (D6010) for tooth number 14, a prefabricated abutment (D6056) for tooth number 14, a bone replacement graft for ridge preservation (D7953) for tooth number 14, sinus augmentation (D7951) and a computed tomography (CT) scan (D0367).
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for imaging services provided to the enrollee on March 25, 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 Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted the claim was not submitted with the correct POS code. The Plan notes these services were provided at a nursing home (via mobile van/portable x-ray). The documentation does not support the studies as billed with a Place of Service code 11 which is for an office as opposed to a facility.
The Plan is correct in this case. The Plan follows Medicare rules. Medicare rules say that providers must report the correct POS code.
These services should have been reported with POS code 31 for the Skilled Nursing Facility, instead of the billed POS code of 11 for the office. Medicare billing criteria were not met Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on March 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay for ambulance transport provided to the enrollee on June 12, 2022.
You asked the Plan to pay for this transport. 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 provider needed to bill with Modifier RP to show the enrollee was transported from their residence to the
physician's office.
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 origin and destination transport indicators. In this case, the claim was not submitted with the
appropriate origin and destination codes. Medicare rules for coverage of this transport have not been met.
Therefore, we decided that the Plan does not have to pay for ambulance transport provided to the enrollee on
June 12, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for a gastrointestinal panel provided on March 10, 2022.
You asked the Plan to pay this claim. You say that this testing should be paid by the Plan. 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 noted that the C-difficile testing was not done via polymerase chain reaction (PCR) as seen in the lab results and therefore do not meet the required LCD requirements. The LCD states gastrointestinal pathogen (GIP) testing is limited to no more than 5 bacterial pathogen targets when not testing for Clostridium difficile. Testing for 6 to 11 pathogens is covered when there is a clinical concern for Clostridium Difficile colitis, and Clostridium difficile is one of the pathogens being tested. Gastrointestinal pathogen panel tests with 6 to 11 pathogens are only medically necessary in the case of Clostridium Difficile colitis suspicion.
There was no PCR testing on C-difficile done in this case.
The Plan is correct in this case. The Plan must follow Medicare rules. Has specific coverage criteria for this type of testing. Based on the records provided by the Plan, those criteria were not met. Therefore, we decided that the Plan does not have to pay for a gastrointestinal panel provided to the enrollee on March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic analysis procedures billed with codes 81286, 81413, 81414, 81442, 81161, and 81479 provided to the enrollee on March 2, 2022.
You asked the Plan to pay for the genetic analysis procedures. You say that you have provided the proper documentation to substantiate the claim submitted. The Plan denied your request. The Plan says that the non-contracted provider did not submit medical documentation to support the medical necessity of the services provided.
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 genetic analysis procedures have been met. The Plan made multiple requests for records, including physician orders, office/visit notes, operative notes and diagnostic lab/pathology reports. There has been no response to the request for records. Therefore, we decided that the Plan does not have to pay for the genetic analysis procedures billed with codes 81286, 81413, 81414, 81442, 81161, and 81479 provided to the enrollee on March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to withdraw the request for recoupment of the overpayment recovery request in the amount of $904.12 for drugs (J0490) provided to the enrollee on November 8, 2021.
You say that you do not believe the Plans request for this recoupment is correct. The Plan denied your request. The Plan says this service was previously paid. Maximus overturned the Plans denial for insufficient information in the case file regarding the paid claim. The Plan requested a reopen and provided a copy of the previously paid claim. The Plan states November 8, 2021, the drug Benlysta (J0490) was incorrectly billed by and paid to you as the provider on claim Claim A. The drug was also billed by and paid to another provide under claim Claim B. The overpayment balance of $904.12 is assessed by the valid rate for code J0490 for 2021 ($452.06 x2). The service was paid twice, and the second claim (211110E2695102) shows authorized the payment for the $904.12. Duplicate payments were made for the drug Benlysta (J0490).
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case the Plan has provided documentation to show this claim was previously paid and that this drug was billed twice for the same date of service.
Therefore, we decided that the Plan does not have to waive the recoupment for the overpayment recovery request in the amount of $904.12 for drugs (J0490) provided to the enrollee on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0210) provided on May 26, 2022.
You asked the Plan to pay for these dental services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided proof of previous payment.
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 this type of service was exhausted on date of service April 4, 2022. Therefore, we decided that the Plan does not have to pay for dental services (D0210) provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incision and drainage of abscess and palliative treatment 
(D7510, D9110) provided on October 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 incision 
and drainage of abscess and palliative treatment (D7510, D9110) provided on October 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging provided on November 13, 2022. 
 
You asked the Plan to pay for imaging. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for imaging provided on 
November 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on September 22, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that this was medically necessary and should 
be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
services provided on September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve chiropractic care. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must get their care from network providers that are affiliated 
with their primary care physician's (PCP's) health network. Usually, the plan won't cover care from a provider 
who doesn't work with the health plan and the enrollees PCP's health network. This means that the enrollee 
will have to pay the provider in full for the services furnished from providers outside of the 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
chiropractic care to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oncology visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an oncology visit. You say that an appointment was missed, then the Plan 
denied future visits with this provider. This is a medical necessity and needs to be covered. The Plan denied 
your request. The Plan says there are multiple in-network providers who can give the same treatment and 
would be covered. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an oncology visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker with accessories to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a walker with accessories. You say that this should be covered, you need it 
so that you do not fall again. The Plan denied your request. The Plan says there are other providers who are in-
network, who can get the walker covered 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a walker with accessories to be provided by an out-of-network (OON) provider.
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. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says criteria for admission 
to the Acute Inpatient Rehabilitation setting have not been met, the enrollee's ongoing skilled therapy and 
nursing needs can be provided at a lower level of care, a Skilled Nursing Facility, on an intermittent basis at 
home with home health care, or in a long-term care setting. 
 
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. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the psychotherapy services provided by an 
in-network provider from October 4, 2022, to October 26, 2022. 
 
You asked the Plan to waive the copayment for the psychotherapy services. You say that you would like the 
cost sharing for these services to be lower. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $50 
copayment for in-network mental health services provided at an outpatient hospital. 
 
 
 
 
 
 You have been asked to pay a $800 copayment for the psychotherapy services. Although your contract lists a 
$50 copayment, the Plan is only holding you responsible for a $40 copayment for each service ($40 x 20 
services = $800). These items/services fall within the outpatient mental health care 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 psychotherapy services provided by an in-network 
provider from October 4, 2022, to October 26, 2022.