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

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) device. 
 
You asked the Plan to pre-approve the ILR device. You say that the enrollee has a history of atrial fibrillation 
and atrial flutter. You also say that an ILR device would be used as a monitoring tool for the enrollee's atrial 
arrhythmias. The Plan denied your request. The Plan says the records do not show the enrollee is having 
syncopal episodes. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 
 
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 ILR device. Our reviewer says that 
the requested ILR device is not medically necessary. Our physician reviewer found while the enrollee has a 
history of atrial fibrillation, there is no documentation provided to suggest a history of unexplained syncope, 
cryptogenic stroke or any other apparent indication for an ILR. In summary, there is insufficient documentation 
to support the medical necessity for insertion of an ILR in the enrollees clinical management.  
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 ILR device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR) device.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an implantable loop recorder (ILR) device. 
 
You asked the Plan to pre-approve the ILR device. You say that recurrent transient ischemic attack (TIA) is a 
coverable diagnosis for an implantable loop recorder. The Plan denied your request. The Plan says that the 
records do not show that the enrollee has hand any syncopal episodes. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 
 
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 ILR device. Our reviewer says that 
the requested ILR device is medically necessary. Our physician reviewer found the documentation supports 
that the enrollee would benefit from this device to document a paroxysmal atrial fibrillation as the source of the 
enrollee's recent transient ischemic attack (TIA). Therefore, the reviewer that the ILR device is medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ILR device have been met. Therefore, we decided that the Plan has to pre-
approve an implantable loop recorder (ILR) device.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on May 22, 2023. 
 
You asked the Plan to pay for the comprehensive oral evaluation. The Plan denied your request. The Plan says 
your benefit for the comprehensive oral evaluation has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 8, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or 
established patient (D0150) provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99344 provided on January 13, 2023. 
 
You asked the Plan to pay for procedure code 99344. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say the Home or Residence Services codes (99341-
99350) should not be used for SNF or NF places of service. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99344 was performed for the 
enrollee in an assisted living facility, which would be place of service code 13 on the claim. You submitted the 
claim with place of service code 31 for SNF. Medicare rules say the Home or Residence Services codes 
(99341-99350) should not be used for SNF or NF places of service. Therefore, we decided that the Plan does 
not have to pay for procedure code 99344 provided on January 13, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is ready to discharge from acute 
inpatient care to a skilled nursing level of care to return to their baseline. The Plan denied your request. The 
Plan says the enrollee does not meet the requirement for admission to a SNF.  
 
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 pre-approve 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/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 pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on October 10, 2022.
You asked the Plan to pay for the chiropractic services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that you have exhausted the allowable benefit for this service. Maximus overturned the Plan's denial. The Plan requested a reopening stating that this benefit was exhausted. The Plan is correct in this case. The Plan has provided documentation confirming you had exhausted your benefit by this date of service by using your twelve (12) chiropractic services visits. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on October 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on June 2, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for SNF services. You say that it is the responsibility of the facility to obtain prior 
authorization. The Plan denied your request. The Plan says these services were rendered without a prior 
authorization on file. 
 
 
 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 facility (SNF) services provided on 
June 2, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service May 28, 
2022. 
 You asked the Plan to pay for procedure code 99291. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99291 is bundled into payment for code 32551. 
 
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 99291 
is a column II code to column I code 32551. 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 99291 billed for date of service May 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical collar (L0180) provided to the enrollee on November 8, 2022.
You asked the Plan to pay for the cervical collar. The Plan denied your request. The Plan says that the submitted medical record did not substantiate the necessity of the neck brace. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that the necessary documentation has not been submitted.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid physician order, proof of delivery and relevant medical records which support medical necessity. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The medical records provided do not discuss the need for this item. 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 cervical collar (L0180) provided to the enrollee on November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on April 07, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that the services 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 an office visit and 
related services provided on April 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve segmental pneumatic appliance and pneumatic 
compressor to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve segmental pneumatic appliance and pneumatic compressor. You say that the 
supplies should e covered. The Plan denied your request. The Plan says this is available 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 
segmental pneumatic appliance and pneumatic compressor 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 pay for the knee x-ray provided on May 16, 2023. 
 
You asked the Plan to pay for the knee x-ray. You say that you are appealing the denial with supporting 
documentation. 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 the knee x-ray provided 
on May 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 21480-54 billed for date of service December 
26, 2022. 
 
You asked the Plan to pay for the billed service. You say that the enrollee was seen for a medically necessary 
procedure. The Plan denied your request. The Plan says split care does not apply. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 21480, billed with the -54 modifier is not supported. The physician who performs the 
emergency room service bills for the surgical procedure without a modifier. Based on this information, we 
decided that Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 21480-54 billed for date of service December 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided on 
March 24, 2023. 
 
You asked the Plan to pay for het pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says a PCD is not covered for preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0676) provided on March 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ECG and spinal surgery provided from 
April 24, 2023, to May 23, 2023. 
 
You asked the Plan to waive the copayments for the ECG and spinal surgery. You say that the Plan did not 
approve the MRI you needed for several months. 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 $5 
copayment for outpatient diagnostic tests. Your contract with the Plan also clearly says that you must pay a 
$250 copayment for outpatient surgery. 
 
You have been asked to pay a $5 copayment for the ECG. This item/service falls within the outpatient 
diagnostic tests and therapeutic services benefit category. You have also been asked to pay a $250 copayment 
for the spinal surgery. This item/service falls within the outpatient surgery benefit category. You have been 
asked to pay a total of $255 ($5 copayment + $250 copayment = $255). 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 copayments for the ECG and spinal surgery provided from April 24, 2023, to May 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided to the enrollee on September 23, 2022.
You asked the Plan to pay for the electrical stimulator supplies. You say that the claim should be paid. The Plan denied your request. The Plan says that since the provider is renting the TENS Unit to the member the provider should not bill for supplies. Maximus overturned the Plan's denial for insufficient information in the case file. The Plan requested a reopen and noted the claim history shows this provider has been submitting claims for the TENS unit (E0730 RR KX) indicating this is a rental item. Per Medicare guidelines, during the rental of a TENS unit, supplies for the unit are included in the rental allowance. There is no additional allowance for items such as electrodes, lead wires, and batteries. As the provider is renting the unit to the enrollee, the provider should not bill for supplies separately based on the Medicare billing guidelines. It is also noted that the provider has billed the plan for 6 units for code A4595 (Electrical stimulator supplies, 2 lead, per month). The provider is billing the units in excess of the Medicare allowed amount. Therefore, this claim was denied correctly.
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, the provider is billing for supplies separately for rented equipment, which is not allowed. The provider is also billing in excess of the normal units allowed by the billing guidelines. Medicare rules for payment of this claim are not met. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided to the enrollee on September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided on January 
26, 2023, by an OON provider.  
 You asked the Plan to pay for the chronic care management services. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chronic care management services provided on 
January 26, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neck brace (L0180) provided to the enrollee on
November 17, 2022.
You asked the Plan to pay for the neck brace. The Plan denied your request. The Plan says that the patient's
medical record must contain sufficient documentation of the patient's medical condition to substantiate the
necessity for the type and quantity of items ordered. Maximus overturned the Plan's denial. The Plan requested
a reopening and stated that the necessary documentation has not been submitted.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid
physician order, proof of delivery and relevant medical records which support medical necessity.
The record does not contain relevant medical records which support medical necessity for the supplies provided
in this case. The medical records provided do not discuss the need for this item. 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 neck brace (L0180) provided to the enrollee on November 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The 
Plan denied your request. The Plan says there is no documentation provided to support the expectation the 
enrollee will require a greater than 2 midnight stay. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found there is no documentation provided to support the expectation the enrollee 
will require a greater than 2 midnight stay to undergo this elective procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.