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

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on June 24, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. 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 skilled nursing facility 
care provided on June 24, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 12, 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 the claim was billed with
a date of service inconsistent with Medicare rules governing laboratory services. The records submitted
show that specimens were collected on February 11, 2022. The specimen was received on April 6, 2022. There
is no documentation of molecular pathology testing performed on the date billed of April 12, 2022. 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.
There is no documentation that the sample was taken in the laboratory. The difference in date of collection and
date received confirms that the was not collected directly by the laboratory. In addition, the claim did not
include the unique test identifier or DEX Z-Code required by Medicare.
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 issues with the dates of
service billed, the POS code billed and the omission of the required test identifier codes. 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 12, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from August 22, 2022, to September 20, 
2022. 
 You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility needs. 
 
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. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from August 22, 2022, to September 20, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the skilled nursing facility (SNF) services provided from January 7, 2022, through January 22, 2022.
You asked the Plan to waive the copay for the SNF services. You say that you should not have a copay for this stay, you believe you are being billed incorrectly. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the Plans denial stating the copay was miscalculated. The Plan requested a reopen and stated that Maximus did not apply the correct dates of service.
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 $184 copay for per day for days 21 through 100 of SNF care. You have been asked to pay a $1,472 copay for the SNF services. The case file indicates you were in a SNF facility from October 29, 2021, through November 10, 2021, with a discharge date of November 11, 2021, for a total of thirteen (13) days. You were then admitted to a SNF from January 7, 2022, through January 21, 2022, with a discharge date of January 22, 2022, for a total of fifteen (15) days. You were in a SNF for a total of 28 days during this benefit period. This means you owe a copay for eight (8) days.
This item/service falls within the days 21 through 100 of SNF 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 copay for the skilled nursing facility (SNF) services provided from January 7, 2022, through January 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy billed under code 97140 
provided on August 10, 2022, to August 12, 2022. 
 
You asked the Plan to waive the copayment for physical therapy billed under code 97140. You say that this 
claim should be processed as in-network. I should not have to pay for these visits. 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 $40 
copayment for Outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for physical therapy billed under code 97140. This item/service 
falls within the Outpatient rehabilitation services 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 physical therapy billed under code 97140 provided on August 10, 2022, to August 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 1, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the member's move out of state affected their 
coverage and the claim has been denied corectly. 
 
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 home health services provided on August 1, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on July 20, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that the enrollee does not have other insurance. 
The Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to submit the claim to the enrollees primary insurance. As the secondary insurer, the Plan cannot be 
held responsible for the outpatient service until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 26, 2022, to September 
06, 2022. 
 
You asked the Plan to pay for an office visit. You say that your other doctor retired, and you started seeing 
someone new in the same office. 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 an office visit provided 
on August 26, 2022, to September 06, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary to treat your 
medical symptoms. The Plan denied your request. The Plan says the Medicare criteria for the CGM were not 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
  We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for wide area transepithelial sampling (WATS) 3D
Histocytology (88361, 88312, 88305, 88104) testing provided March 22, 2021.
You asked the Plan to pay for these services. You say that this testing was medically necessary. The Plan
denied your request. The Plan says the enrollee does not have a qualifying diagnosis. Maximus overturned the
Plans denial. The Plan requested a reopen and stated Maximus did not interpret the medical records correctly.
The Plan noted that the medical records indicate the enrollee had an elective Esophagogastroduodenoscopy
(EGD) performed March 22, 2021, for diagnoses of heartburn, chronic cough, and abdominal pain for two
weeks.
The EGD biopsies showed changes consistent with reflux esophagitis and focal intestinal metaplasia. The
WATS 3D Histocytology report showed no dysplasia present and there was no documentation or evidence of
Barrett's.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. Medicare rules state the medical records must
support the services billed. In this case this testing was ordered after an EGD done for symptoms only having
been present for two weeks. There is not confirmation before or after the testing of Barrett's disease. Medical
necessity has not been established. Therefore, we decided that the Plan does not have to pay for wide area
transepithelial sampling (WATS) 3D Histocytology (88361, 88312, 88305, 88104) testing provided March 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee pain 
related to osteoarthritis. She has not tried and failed the Plan's required drugs, Synvisc/Synvisc One or 
Euflexxa. The records do not show that the required drugs would be contraindicated or less effective; therefore, 
Supartz is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on December 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 the 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 information. The
Plan noted that, 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, which would be POS 21 or
22. 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 due to errors with the POS code submitted and the lack of
documentation to show the testing was valid at the time of service. Therefore, we decided that the Plan does not
have to pay for genetic testing provided to the enrollee on December 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a spinal cord stimulator trial coded as 63650 and L8680 for the enrollee.
You asked the Plan to provide coverage for a spinal cord stimulator trial coded as 63650 and L8680. You say that at the time of the appeal, this device was 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 notes the medical records show the enrollee reported back and bilateral leg pain. Imaging of the lumbar spine showed degenerative changes of the lumbar spine without significant stenosis. The diagnoses were radiculopathy and chronic pain syndrome. Spinal cord stimulation is non-covered by Medicare for "radiculopathy" without neural injury or neural compression. Therefore, the required criteria were not met
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for this device. Based on the medical records provided, the enrollee does not meet all the criteria required for coverage and was diagnosed with a condition that does not allow use of this device under Medicare guidelines. Therefore, we decided that the Plan does not have to provide coverage for a spinal cord stimulator trial coded as 63650 and L8680 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 3, 2022, 
through June 4, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee was transferred from an outside facility to the emergency department (ED) on 
June 3, 2022, status post a fall from a motorized scooter. He sustained a right bimalleloar fracture. He was 
evaluated in the ED with a cervical collar and was given intravenous fluids, Fentanyl, and Valium. He 
underwent computed tomography (CT) scans of the head, cervical spine, and abdomen and pelvis, with x-rays 
of the right foot and right tibia/fibula. The fracture was confirmed. He was evaluated by Orthopedics and the 
ankle was reduced. No surgical intervention was required. He was admitted and on June 4, 2022 was 
considered medically stable with scheduled outpatient orthopedic follow-up. The review has determined that 
the record did not show that at the time of the inpatient admission, the admitting physician reasonably expected 
that the enrollees necessary hospital care (including earlier ED and/or observation care) would span two 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from June 3, 2022, through June 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport and ground mileage provided on May 19, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, emergency transport and ground 
mileage. You say that the enrollee met medical necessity for the trip and have submitted supporting medical 
records and waiver of liability for review. The Plan denied your request. The Plan says this claim does not meet 
the requirements for the transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the ambulance service, basic life support, 
emergency transport and ground mileage.  Our reviewer says that the transportation via ambulance from the enrollee's dialysis appointment to home was 
not medically necessary. Our physician reviewer found the enrollee did not require the expertise of trained 
personnel or the equipment available only on an ambulance in order to effectuate a safe transport. 
Transportation could have been provided by other means (stretcher van, wheelchair van)without endangering 
the enrollee's condition. 
 
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 ambulance service, basic life support, emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, 
basic life support, emergency transport and ground mileage provided on May 19, 2022.