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

 
We decided that the Plan does not have to pay for a medical eye exam provided on May 03, 2023. 
 
You asked the Plan to pay for a medical eye exam. You say that the enrollee was in a nursing home setting at 
the time services were rendered. 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 a medical eye exam 
provided on May 03, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye exam provided on May 03, 2023. 
 
You asked the Plan to pay for eye exam. You say that you are appealing the claim payment denial. 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 eye exam provided on 
May 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service February 21, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87653 and 87798. You say that these services are 
supported in the medical record. The Plan denied your request. The Plan says these services are not supported 
for separate billing and payment. 
 
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 codes 87481, 87653 and 87798 are column II codes to column I code 
87801; however, 87481, 87653 and 87798 were each billed with a modifier.  
 
We asked our coder 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 procedure codes 87481, 87653 and 87798. Our reviewer says 
that these codes are not supported as unbundled services. Our reviewer found although these codes were 
reported with the XU modifier, the laboratory report does not include documentation of rationale of the codes 
and modifier reported, and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481, 87653 and 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye exam provided on May 23, 2023. 
 
You asked the Plan to pay for a medical eye exam. You say that the provider was not responsible for obtaining 
authorization. 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 a medical eye exam 
provided on May 23, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for you disagree with the copayment. provided 
on May 01, 2023. 
 
You asked the Plan to reduce the copayment for you disagree with the copayment.. You say that you disagree 
with the copayment. 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 $200 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $200 copayment for you disagree with the copayment.. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies 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. However, since the allowed amount is 
less than the standard copayment, you only owe $115.62. Therefore, we decided that the Plan does not have to 
reduce the copayment for you disagree with the copayment. provided on May 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an esophagogastroduodenoscopy (EGD) with placement of 
gastrostomy tube, and related services provided on September 06, 2022. 
 
You asked the Plan to pay for an esophagogastroduodenoscopy (EGD) with placement of gastrostomy tube, 
and related services. You say that this is supported in the records. 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 
esophagogastroduodenoscopy (EGD) with placement of gastrostomy tube, and related services provided on 
September 06, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation level of care provided from September 29, 
2021, to October 1, 2021. 
 
You asked the Plan to pay for the observation level of care. You say that based on the information provided, 
you believe medical necessity was established. You also say that you would like the procedure to be authorized 
and payment to be approved in accordance with the benefits quoted at the time of the enrollee's admission. The 
Plan denied your request. The Plan says the medical records received show that the enrollee was 
hemodynamically stable with no new clinical findings and/or treatments that would require a continued 
inpatient stay beyond September 28, 2021. 
 
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 pay for the observation level of care. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found as of September 28, 2021, the enrollee was hemodynamically stable without hypoxia 
or respiratory distress. The enrollee was tolerating oral medications. Our reviewer also found that the 
observation care provided from September 29, 2021, to October 1, 2021, was not medically reasonable or 
necessary based on the medical records provided. 
 
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 observation level of care have not been met. Therefore, we decided that the 
Plan does not have to pay for the observation level of care provided from September 29, 2021, to October 1, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent antigen detection by immunoassay 
technique (87389) provided January 5, 2023.  

You asked the Plan to pay for the laboratory service. You say that kindly reconsider and process the claim 
towards payment. The Plan denied your request. The Plan says this testing is not a Medicare benefit for the 
diagnoses listed on the claim and are done for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory service, was requested solely for screening purposes. The claim 
was billed with diagnosis code Z11.4: encounter for screening for human immunodeficiency virus [HIV]. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the infectious agent antigen detection by immunoassay technique (87389) provided January 5, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond September 
8, 2023.  
 
You asked the Plan to pre-approve the continued inpatient psychiatric care. You say that the enrollee requires 
continued inpatient care.  The Plan denied your request. The Plan says the enrollee's needs can be met in a less 
restrictive setting. No active treatment is taking place.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric care. 
Our reviewer says that the inpatient level of care is not medically necessary beyond the date at issue. Our 
physician reviewer found the enrollee was admitted to the inpatient psychiatric level of care due to an increase 
in delusional behavior and paranoia. The plan of care included medication administration and therapy. It 
appears that the beneficiary has reached maximum benefit from her inpatient psychiatric stay at the current 
facility.   The beneficiary is noted to continue to be delusional and has not complied with medication 
administration. The documentation indicates the current facility is mostly giving custodial care. The progress 
notes do not indicate that the beneficiary has been aggressive with peers or staff on the unit or has had any 
recent attempt to harm herself during the disputed period. As of the last covered day, there is no indication in 
the available medical records that the beneficiary's psychiatric symptoms require continued care in the current 
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 the continued inpatient psychiatric care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond September 8, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E1399). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee has multiple 
conditions that would benefit from the use of the requested hospital bed. The Plan denied your request. The 
Plan says the requested hospital bed is not covered; the height adjustment feature is a convenience feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E1399).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on April 19, 2023. 
 
You asked the Plan to waive the copayment for ambulance. You say that you say that you had no choice to 
receive ambulance services at the time. 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 $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 copayment for ambulance. This item/service falls within the ambulance 
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 ambulance provided on 
April 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee during outpatient surgery on December 1, 2022.
You asked the Plan to pay for this claim as billed. You say that this equipment should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus upheld the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers.
This equipment was used during and after a surgical procedure by the facility to treat the enrollee. This equipment did not go home with the enrollee. Payment for this service would have been included under the facility claim. Payment to you as the provider for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee during outpatient surgery on December 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.
You asked the Plan to pre-approve Aranesp. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the enrollee does not meet step therapy criteria for this drug. Maximus overturned the Plan's denial for medical necessity. The Plan requested a reopening and confirmed the denial was not for medical necessity but for the enrollee not meeting step therapy criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Aranesp. Our Medical Director states that the case file does not contain documentation of trial and failure of Procrit or Retacrit. The documentation does not support that Procrit or Retacrit would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Aranesp. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), backup camera bracket (A9270) and backup camera (A9270) for the enrollee.
You asked the Plan to pre-approve an electronic connection, backup camera bracket and backup camera. You say that these items are medically necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria have not been met.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic connection. Our Medical Director states that the documentation supports that the enrollee's upper extremity strength and function appear to be adequate to operate the power options using their own switches. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of an electronic connection. We looked at this physician's review, the file, and Medicare rules. The back camera bracket and backup camera do not serve a medical purpose. Based on this information, we decided that Medicare rules for coverage of an electronic connection, backup camera bracket and backup camera have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), backup camera bracket (A9270) and backup camera (A9270) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by a chiropractor on May 2, 2023. 
 
You asked the Plan to pay for the office visit. You say that this service should be covered because you have 
seen this doctor in the past and this is the first time you are getting denied. The Plan denied your request. The 
Plan says the only covered chiropractic service is manual manipulation of the spine. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided by a chiropractor on May 2, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on May 27, 2022, to July 21, 2022. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you were advised 
the copayment would only be $10. 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 each physical therapy (PT) visit. 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. The total you owe for PT services is $440 ($40 per visit x 11 visits = $440). 
Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit 
provided on May 27, 2022, to July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on March 27, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this patient is in a facility, and you depend upon the 
facility staff for any verification or prior authorization. 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 a facility visit provided 
on March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 23, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 November 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311) for a power 
wheelchair. 
 
You asked the Plan to pre-approve an electronic connection. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not medically 
necessary. 
 
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 an electronic connection. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has sufficient strength and function in upper extremities to manage standard 
power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311) for a power wheelchair.