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

We decided that the Plan does not have to pay for dental services provided on January 17, 2023.

You asked the Plan to pay for these dental services. The Plan denied your request. The Plan says this service is
not a covered benefit. Maximus overturned the Plans denial. The Plan requested a reopen and noted these
dental services denied because they are a non-covered service. The Evidence of Coverage pages 70 through 71
does not show coverage for extractions under the Mandatory Supplemental Dental Benefit (DEN353). There
are additional Dental Benefits included in the contract beginning on page 75 through 83 that are available for
an additional cost of $49.80 per month. You were not enrolled in this additional dental program on the date of
service.

The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a supplemental dental
benefit. Therefore, the Plans rules apply in this case.

The service provided is only covered for enrollees who pay an additional premium for an upgraded dental
benefit. You were not enrolled in that additional benefit on the date of service. Therefore, we decided that the
Plan does not have to pay for dental services provided on January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan has to pay for SelectMDx testing provided on August 26, 2022.

You asked the Plan to pay for SelectMDx testing. You say that this testing was medically necessary and is covered by Medicare. The Plan denied your request. The Plan says that the request does not meet the Medicare rules because a review of the published literature and clinical practice guidelines does not support this testing as a means to determine which men should undergo prostate biopsy.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pay for SelectMDx testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found that SelectMDx is medically reasonable and necessary for the enrollee in this case. The enrollee does not have an established diagnosis of prostate cancer, has not had a prostate biopsy, but is a candidate for a prostate biopsy which would potentially impact management. The medical record supports the medical necessity of this test.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SelectMDx testing have been met. Therefore, we decided that the Plan has to pay for SelectMDx testing provided on August 26, 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: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for the upgraded electronics (E2377, E2313, and
E2311).

You asked the Plan to provide coverage for the upgraded electronics (E2377, E2313, and E2311) 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 noted that E2377 Expandable Controller, E2313 Expandable Controller Harness and E2311
electronic accessory are requested to control power tilt, recline, and power elevating leg rests through the
joystick. The notes state that these are needed when 3 or more actuators are being used. The electrical
connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377)
and harness (E2313) cannot be covered. The Plan states the medical records do not show there is not a medical
need to control these power options through the joystick. The medical records show the enrollee has 4/5
bilateral upper extremity strength and can ambulate using a front wheeled walker. The records show the
enrollee's upper limb strength and function are adequate to control the power options using their own switches
which are included in the allowance of these power options.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for the requested accessories. Given the enrollee's upper extremity strength, the clinical documentation does
not support that an upgraded electronic connection is medically reasonable and necessary. Therefore, we
decided that the Plan does not have to provide coverage for the upgraded electronics (E2377, E2313, and
E2311) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from April 11,
2022, to May 10, 2022.

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. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan notes that the
diagnosis code submitted on the claim is stated to be Parkinson's disease. The documentation included with the
appeal does not support the billed primary diagnosis as the reason for the home care provided. The physician
documentation does not support the diagnosis billed. The skilled nurse visits also do not show the care
provided.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to
determine whether payment is due and the amount of payment. We looked at the file and the Medicare rules.
Based on this information, we decided that there is insufficient information in the record to determine if
Medicare rules for coverage of these services were met as the primary diagnosis code is not supported in the
medical records. Therefore, we decided that the Plan does not have to pay for home health services provided to
the enrollee from April 11, 2022, to May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for genetic testing.

You asked the Plan to provide coverage for genetic testing. You say that at the time of the appeal, this testing
was medically necessary. 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 Maximus did not apply the
correct criteria.

The Plan noted that the review did not apply all of the criteria in NCD 90.2. The Plan noted the medical records
show a diagnosis of aggressive systemic mastocytosis. The most recent records provided were for a telehealth
visit on March 21, 2022. At that point you were not receiving any treatment and were reluctant to try any new
medication due to concern for side effects. You wanted to continue surveillance. It is noted that you had NGS
testing previously (though report not made available). An order for this repeat lab testing was placed on
January 9, 2023, without any associated office visit or medical notes. Requests were made for more recent
medical documentation, but none were received. The Plan noted there was insufficient medical record
documentation to show you met all of the required criteria in NCD 90.2

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we
decided that there is insufficient information in the record to determine if all of the Medicare criteria for the
request testing were met at the time of the appeal. Therefore, we decided that the Plan does not have to provide
coverage for genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 01402-QK-P3 provided on August 11, 2022.

You asked the Plan to pay for this service. The Plan denied your request. The Plan says the claim was not billed
with the required modifier. Maximus overturned the Plans denial. The Plan requested a reopen and noted this
claim denied because the Plan previously paid for this service under another claim. The Plan made payment
under claim 820222370268710 for the same date of service to another provider. Both providers have the same
specialty of Anesthesiology and are in the same provider group. An appropriate modifier including 59, XE, XP,
XS, XU was not reported on the second claim to represent the services as separate and distinct.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one
service is provided on the same day to the same patient by the same physician or more than one physician in
the same specialty in the same group, only one service may be reported unless the services are for unrelated
problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group
relationship between the two providers and the omission of the modifier required to identify this as a separate
and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have
to pay for procedure code 01402-QK-P3 provided on August 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care billed with code 99232 for date of service 
February 14, 2023. 
 
You asked the Plan to pay for code 99232 billed for date of service February 14, 2023. You say that you would 
like this claim to be reconsidered and reprocessed for payment. The Plan denied your request. The Plan says no 
records have been received to support the service billed. 
 
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, the CPT Code Manual definition of code 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded.  
 
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 code 99232 billed for date of service February 14, 2023. Our 
reviewer says that the criteria for coverage have not been met. Our reviewer found no records for the date of 
service in question have been identified for review.  As such, the billing of code 99223 on February 14, 2023, 
is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99232 billed for date of service February 14, 2023, have not been met. 
Therefore, we decided that the Plan does not have to pay for initial hospital care billed with code 99232 for 
date of service February 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for imaging services provided to the enrollee on September 1, 2022.

You asked the Plan to pay for this service. 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 noted that this claim denied because the "Place of Service" code was inappropriately
billed. The Plan notes the enrollee was in inpatient status during this service. The provider inappropriately
billed as Outpatient status as the POS code.

The Plan is correct. The Plan must follow Medicare rules. Medicare rules say that providers must report
services correctly. In this case, this claim was billed with an incorrect Place of Service code. Medicare rules for
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for
imaging services provided to the enrollee on September 1, 2022.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99283 for date of service June 1, 2023.

You asked the Plan to pay for procedure code 99283. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the service at issue was not billed with the required modifier to allow separate payment within the global surgery period.

The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical procedures, which should be billed with modifier -79. 

We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 30901 provided on the same date of service. We find that the service at issue may be unrelated to the surgical procedure; however, the required modifier to indicate this was not used. As such, the billing rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99283 for date of service June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99152 and 99153 provided on May 31, 
2023. 
 
You asked the Plan to pay for procedure codes 99152 and 99153. 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 supported. 
 
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, the CPT Code Manual definition of code 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not document 
the presence of an independent trained observer to monitor the level of consciousness.  
 
Additionally, the review shows that the medical records provided represent professional charges; however, 
procedure code 99153 was provided in a facility with a place of service code of 22. Procedure code 99153 has a 
PC/TC Modifier Status of 3, which specifies a Technical Component only code. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 99152 and 99153 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99152 and 
99153 provided on May 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for  acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission 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 noted that Maximus did not apply the correct criteria. The Plan noted the medical records show at the time of the appeal, you were not reasonably expected to be able to fully participate in intensive therapy at the IRF. After your surgery, you were not supposed to put weight on the left foot. 
You also had severe pain and urinary retention issues. You were awaiting approval of a power wheelchair.  During your inpatient short therapy sessions, you required sitting and rest break due to fatigue. The Plan states IRF admission is non-covered by Medicare unless you can be reasonably expected to actively participate in, and benefit significantly from, the intensive rehabilitation therapy program. 

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. Based on the medical records provided, you were not expected to be able to participate in at least three hours of therapy per day at least five days per week. Therefore, we decided that the Plan does not have to provide coverage for  acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for facility to facility ambulance transport provided to the
enrollee on November 22, 2022.

You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your
request. The Plan says payment for this transport is the responsibility of the facility. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan noted the hospital that billed for inpatient charges from November 21, 2022, to November 27, 2022,
is the origin point of the transportation that occurred on November 22, 2022, meaning that the enrollee was
picked up and taken to another campus for specialty treatment and then returned to the original facility. As the
enrollee was an inpatient on the date of transport, payment for these services would be the responsibility of the
originating facility.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. This was a facility to facility transfer of an inpatient status enrollee. Payment for these
services is the responsibility of the facility. Therefore, we decided that the Plan does not have to pay for facility
to facility ambulance transport provided to the enrollee on November 22, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continued skilled nursing facility (SNF) care
beyond March 24, 2023.

You asked the Plan to provide coverage for continued SNF care. You say that at the time of the appeal, SNF
admission was medically necessary. The Plan denied your request. The Plan says the Medicare coverage
criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct criteria. The Plan noted that the medical records show as of March 22, 2023,
your needs were custodial in nature, which is not covered by Medicare.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care
in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

Based on the medical records provided, as of March 22, 2023, you no longer had daily skilled nursing needs
that required the specialized skill, knowledge, and judgment of a skilled professional nurse. You did not have
daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled
professional therapist. Nor did you require daily skilled nursing and/or skilled therapy on an inpatient basis in a
skilled nursing facility (SNF) setting. At that point your care was custodial, which is not covered by Medicare.
Therefore, we decided that the Plan does not have to provide coverage for continued skilled nursing facility
(SNF) care beyond March 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, the progressive lens, and the other lens options 
provided on June 12, 2023. 
 
You asked the Plan to pay for the vision services. You say that you should be reimbursed at least $200 for the 
eyewear. The Plan denied your request. The Plan says the provider was out-of-network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network and you do not have 
out-of-network benefits for eyewear. Based on this information, we decided that the Plan's rules for coverage of 
the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the frames, 
the progressive lens, and the other lens options provided on June 12, 2023.