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

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are disabled for 
bipolar & schizophrenia. You get electric shock treatments (ECT) every week. You also have uncontrolled high 
blood pressure. 
You also say that you have been going to the doctor for HBP every two weeks. The Plan denied your request. 
The Plan says additional trips would exceed your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 trips per year.  We looked at your request, the records in the case file, and the rules. The records show that you have used 
sixteen (16) one-way transportation trips out of the allowed twenty (20) one-way trips approved. Once 20 trips 
are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for coverage 
of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional routine transportation trips (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmented pneumatic compression device. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says a 
standard pump is supported for your needs. 
 
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications.  
 
 
 We looked at the file and Medicare rules. The records do not show that you have lymphedema that extends into 
the chest, trunk, or abdomen. The records do not include a failed response to a basic pum. Based on this 
information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a segmented pneumatic compression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (CGM) supply 
allowance provided on February 23, 2022. 
 
You asked the Plan to pay for the CGM supply allowance. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the items rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order for the supplies provided in this case. Review of the file 
shows that the ordering provider's office did not write the order for the supply allowance provided. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (CGM) supply 
allowance provided on February 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 74177 and 76377 billed for date of service 
March 18, 2022. 
 
You asked the Plan to pay for procedure codes 74177 and 76377. You say that the enrollee had multiple exams 
on this date of service and the attached reports support the level of service. You say that the claim should be 
reconsidered for processing The Plan denied your request. The Plan says payment for code 74177 is bundled 
into payment for code 74178 and payment for 76377 is bundled into payment for code 70498. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 74177 
is a column II code to column I code 74178. CPT code 74177 has not been billed with an appropriate modifier 
to bypass the edit. We have also confirmed that code 76377 is a column II code to column I code 70498 with a 
modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
74177 and 76377 billed for date of service March 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept intraosseous basivertebral nerve ablation 
procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure would be beneficial for 
the enrollee's condition. The Plan denied your request. The Plan says this procedure is not currently supported 
by peer-reviewed literature. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept intraosseous basivertebral nerve ablation procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service March 15, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 36573. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 
is a column II code to column I code 36573. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 71045 billed for date of service March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for these services under the Medicare benefit.
You asked the Plan for these services. You say that this claim should be paid. The Plan denied your request. The Plan says these services must be addressed under your Medicaid benefit. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services). These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to pay for inpatient care provided on June 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device insertion. 
 
You asked the Plan to pre-approve the Vertiflex device insertion. You say that the enrollee has suffered from 
this condition for 20 years and has failed more than 6 months of conservative approaches to treatment. You say 
that the Vertiflex procedure is safe and effective and should be approved. The Plan denied your request. The 
Plan says this procedure has not been found to be helpful for the enrollee's condition. 
 
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 Vertiflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Vertiflex device is experimental, and more research is needed. 
 
 
  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 Vertiflex device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex device insertion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on September 1, 2021, by 
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 14, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for CT scan with calcium scoring.
You asked the Plan to provide coverage for this imaging. You say that this imaging was 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.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a computed
tomography scan with coronary calcium scoring. Maximus determined that a CT scan of the heart with
quantitative evaluation of coronary calcium is medically necessary. The reviewer found you took Atorvastatin
for hyperlipidemia, and had an abnormal cardiac stress echo, and as such was symptomatic for CV symptoms
and qualified for the requested CT calcium scoring. The Plan requested a reopen and argues that the medical
records support that you were not symptomatic. The Plan also notes that the enrollee did not have an abnormal
stress echocardiogram, but rather had an equivocal test, and that a stress echocardiogram on February 24, 2022,
was negative for ischemia.
The medical records show you have a medical history that includes multiple strokes, hypertension, and
hyperlipidemia. At a cardiology appointment on February 1, 2022, it is documented that an exercise tolerance
test was non-diagnostic on October 14, 2021, with less than 1mm down sloping inferior/lateral ST depression.
You were able to walk for 6 minutes.
The records provided do not show that you met the criteria needed for a computed tomography scan of the
heart, without contrast material, with quantitative evaluation of coronary calcium. While you do not report
anginal symptoms, you did have an unclear stress test result, which is an indication for coronary computed
tomography angiography. However, this type of study is not to be used as an alternative to stress testing, as
further evaluation with a stress echocardiogram was recommended. In addition, Medicare guidelines state that
quantitative calcium scoring is not a covered service and will be denied as not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this imaging have not been met. Therefore, we decided that the Plan does not
have to provide coverage for CTA with calcium scoring.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the cost share for services provided on February 17, 2022.
You asked the Plan to waive this cost share. You say that you had the same type of services in January of 2021, and you do not believe this cost share is correct. The Plan denied your request. The Plan says that this cost share was applied based on the Plan contract agreement. Maximus upheld the Plans denial. You then requested an ALJ hearing. The ALJ remanded the case back to Maximus and referenced the fact that neither the Plan nor Maximus submitted a copy of the 2022 Evidence of Coverage for review. Maximus reopened the case remanded back from the ALJ and has found while a 2022 Evidence of Coverage was requested from the Plan, only the 2021 Evidence of coverage was submitted by the Plan for review.
We find the ALJ to be correct in this case. 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. A 2022 Evidence of Coverage should have been submitted for review since the Plans stated date of service was February 17, 2022. During the Maximus appeal review, it was necessary for Maximus to request both a complete case file and a 2022 Evidence of Coverage from the Plan. In both the case file submitted by the Plan and the response to our request for the 2022 Plan contract, the Plan only submitted select pages of the 2021 Evidence of Coverage for review. Maximus completed the review in error with the 2021 contract information. We now find the Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to review your request. The Plan failed to provide a copy of the 2022 Evidence of Coverage for review. Since the Plan states the issue on appeal is cost share for the February 2022 visit, the 2022 contract would be needed to substantiate the Plans denial. Therefore, we decided that the Plan must administratively waive the cost share for services provided on February 17, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing care provided on December 9, 2021, to 
December 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing care. You say that you want the Plan to pay for these services. 
The Plan denied your request. The Plan says the services were not emergent, or urgent and were not approved 
of 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 skilled nursing care provided on December 9, 
2021, to December 15, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 72125-26 billed for date of service January 26, 2022. 
 
You asked the Plan to pay for code 72125-26. You say that this claim was denied as a duplicate in error. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 9, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 72125-26 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 72125-26 billed for date of service January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were billed correctly and are 
supported in the medical record. The Plan denied your request. The Plan says you billed with an incorrect place 
of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045-26 billed for date of service February 
22, 2022. 
 
You asked the Plan to pay for code 71045-26. You say that this claim denied as a duplicate in error. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 5, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 71045-26 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 71045-26 billed for date of service February 
22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request cannot be approved without six weeks of provider-directed treatment being 
completed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that the most recent 
neurological exam is negative. There is no evidence of weakness or reflex absence. There are no recent plain x-
rays, electromyography, or nerve conduction study. There is no stated contraindication to six weeks of physical 
therapy as a conservative attempt at management. Without these things, the medical necessity of the requested 
MRI has not been established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the cervical spine.