Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 x7). 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the provided 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate any further skilled nursing visits beyond what have already been approved. Records 
document the enrollee has been educated on her disease process and medications (though some reinforcement 
is still needed). The two additional nursing visits that were just approved should be able to address the 
educational deficits. No medical notes from the enrollees treating physician are provided documenting a need 
for additional skilled nursing services beyond what have been approved. Records do not document the need for 
intravenous medications, new tube feeding or ostomy care or complex wound care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing (G0299 x7).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from May 
23, 2023, to June 9, 2023. 
 
You asked the Plan to pay for SNF care. You say that the services provided should be paid under the Medicare 
Act. The Plan denied your request. The Plan says the enrollee did not meet the criteria for SNF stay from May 
23, 2023, to June 9, 2023. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no identifiable skilled nursing or skilled therapy service needs. These 
services are not needed on a daily basis. The enrollee does not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for the skilled nursing facility (SNF) stay provided from May 23, 2023, to June 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation (97032), ultrasound therapy 
(97035), mechanical traction therapy (97012), manual therapy techniques, and therapeutic activities (97530) 
provided by a chiropractor on March 31, 2023, to, July 7, 2023. 
 
You asked the Plan to pay for the electrical stimulation (97032), ultrasound therapy (97035), mechanical 
traction therapy (97012), manual therapy techniques, and therapeutic activities (97530). You say that you were 
told that the chiropractor was not in your network, and you had to have prior authorization. You say that you 
were new to the area and did not know any specific doctors to go to. 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 the electrical stimulation (97032), ultrasound therapy (97035), mechanical 
traction therapy (97012), manual therapy techniques, and therapeutic activities (97530) provided by a 
chiropractor on March 31, 2023, to, July 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the upgraded electronics are not covered as there is not a medical need to 
control the requested power options through the joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found according to Medicare, a power mobility device is medically necessary if an enrollee 
has a mobility limitation that significantly impairs his ability to participate in one or more mobility-related 
activities of daily living. The mobility limitation cannot be sufficiently and safely resolved by the use of a fitted 
cane or walker, or the enrollee does not have sufficient upper extremity function to self-propel an optimally 
configured manual wheelchair. The enrollee must also have the mental and physical capabilities to safely 
operate the power wheelchair and the home provides adequate access between rooms, maneuvering space, and 
surfaces for the operation of the PWC. The requested electrical accessories are not medically necessary as the 
enrollee does have use of the upper extremity and can operate and control the power options using the switches 
that are included in the basic wheelchair. There is not a medical need for the upgraded electronics. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the add tooth to an existing partial denture for tooth number 
29 (D5650) provided on June 22, 2023. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the dental item provided 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 Plan's 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 item provided was exhausted on date of service June 22, 2023. Specifically, the 
Plan's contract states that an add tooth to an existing partial denture is covered once per calendar year. The 
record shows that on this day, you also received an add tooth to a partial denture for tooth number 19 that was 
paid for by the Plan. Therefore, you have exhausted the allowable benefit for this dental item. Therefore, we 
decided that the Plan does not have to pay for the add tooth to an existing partial denture for tooth number 29 
(D5650) provided on June 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there is no indication that the 
enrollee has failed bilevel positive airway pressure (BIPAP) or had worsening disease or response to current 
therapy.  No arterial blood gas (ABG) or compliance report provided. Hence, no indication for escalation of 
therapy given lack of data or documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with codes 88305 and 88333 for date of 
service November 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have supplied medical records to support 
payment. 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 May 3, 2023. 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 the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services billed with codes 88305 and 88333 for date of 
service November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral periapical x-rays billed with code D0220 for
October 25, 2022.

You asked the Plan to pay for these dental services. You say that you disagree with the denial. The Plan denied
your request. The Plan says your benefit for the requested item or service 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 Plan's coverage rules apply in this case. The Plan reimburses up to
$500 per year for preventive dental services.

Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The previous
determination stated that the Plan did not provide documentation to prove you had used all $500 of your
supplemental benefit allowance.

The Plan submitted documentation to support that you utilized the full reimbursement amount of $500 as of
October 25, 2022. The Plan reimbursed you for the dental exam and cleaning on October 25, 2022, and the
charges of $64 and $109 for these services met the $500 allowance. Further reimbursement is not covered by
your supplemental benefit or Medicare benefit. Therefore, we decided that the Plan does not have to pay for the
intraoral periapical x-rays billed with code D0220 for October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management (E&M) (code 99233)
provided on July 11, 2022.

You asked the Plan to pay for this claim. The Plan denied your request. The Plan says the Medicare billing
criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The
Plan requested a reopen and provided additional documentation. The Plan provided the previous claim that
shows the enrollee was billed for code 99233 under claim number 22I9679188-00 for July 11, 2022, with the
same provider.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. We show this enrollee was previously billed for the same date of service and for the
same code by the same provider. There is no indication in the second claim under review that this was a
separate and distinct service. Therefore, we decided that the Plan does not have to pay for the evaluation and
management (E&M) (code 99233) provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the bitewing x-rays provided on October 26, 2022.

You asked the Plan to pay for the bitewing x-rays. You say that you would like this covered. The Plan denied
your request. The Plan says that your benefit for the requested item or service has already been exhausted.
Maximus overturned the Plan's denial for lack of information. The Plan requested a reopening and stated that
the enrollee's benefit for this service has been exhausted. The Plan is incorrect in this case. 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. Though the Plan offers a dental benefit in excess of
Medicare coverage, certain limitations apply. The Plan has not made reasonable and diligent efforts to gather
and forward to us information regarding their decision to deny your request. There is no evidence showing your
benefit for the requested item or service was previously exhausted. The Plan has shown you received a
panoramic radiographic image previously but has not shown you received bitewing x-rays. Therefore, we
decided that the Plan has to pay for the bitewing x-rays provided on October 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on January 13, 2023, under
code 76642 and billed under Claim A.

You asked the Plan to pay for this claim. The Plan denied your request. The Plan says this claim is a duplicate
of a previously paid claim and was correctly denied. Maximus overturned the Plans denial for a lack of claim
information in the file. The Plan requested a reopen and provided the required claim information.

The Plan is correct in this case. 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. We looked at the
file and Medicare rules. The Plan has provided documentation to show this claim was previously submitted by
the same provider, for the same date of service, for the same code and billed to the same enrollee. Therefore,
we decided that the Plan does not have to pay for services provided to the enrollee on January 13, 2023, under
code 76642 and billed under Claim A.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Freestyle Libre 2 continuous glucose monitor
(CGM) sensor.

You asked the Plan to provide coverage for this device. The Plan denied your request. The Plan says the
services are not covered. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are
considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three
daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing
results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen
and diabetes treatment plan.

We looked at the file and Medicare rules. The previous determination stated that the Plan did not provide
medical records from the participating provider to support their determination; however, the Plan has since
submitted relevant medical records to show that the criteria for coverage are not met. The documentation
indicates that the enrollee does not treat with insulin. Based on this information, we decided that Medicare rules
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to provide
coverage for a Freestyle Libre 2 continuous glucose monitor (CGM) sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says that these services are not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Kenevo
microprocessor knee and flex-walk foot. Our Medical Director states that the documentation does not
sufficiently support that the complexity of your nursing, medical, and rehabilitation needs required an acute
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation is
insufficient to support that you require at least 3 hours a day for 5 days a week, or 15 hours over 7 consecutive
days, of therapy services. Our Medical Director found that your condition does not meet Medicare criteria for
IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay the second claim billed for code 99233 for date of service January
13, 2023.

You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria
were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional
information. The Plan provided an additional claim which shows code 99233 was billed more than once for this
date of service by the same servicing provider.

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 only one service may be reported
unless the services are for unrelated problems. Based on the documentation provided, this code was previously
billed by the same provider and paid by the Plan. There was no indication that the second claim billed was a
separate and distinct service unrelated to the first claim billed by the same provider. Therefore, we decided that
the Plan does not have to pay the second claim billed for code 99233 billed for date of service January 13,
2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided to the enrollee on
September 20, 2022.

You asked the Plan to pay this claim. You say that these services should be paid by the Plan. The Plan denied
your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial
for insufficient information in the case file. The Plan requested a reopen and noted there was a clerical error in
the summary provided in the case file. The Plan states this summary incorrectly advised "the procedure code
77049 has a status indicator of "B". The Plan states it should have advised that "the procedure code 99211 had
a status indicator of B", and "Additionally, procedure code 85018 and 85610 denied as "0992" for "please
correct OCE edit error on other claim line" due to RTP disposition available for OCE edit 62".
The summary reason was correct; however, the incorrect codes were mentioned within the original case
summary.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, this claim
could not be paid due to their status indicator in the OCE system. The Plan noted a corrected claim would be
reviewed.

Based on this information, we decided that Medicare rules for payment of this claim was original billed were
not met. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided to
the enrollee on September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide continued coverage for a hospital bed.

You asked the Plan to provide continued coverage for a hospital bed. You say that continued use of this
hospital bed is medically necessary. The Plan denied your request. The Plan says as the hospital bed was
received on March 22, 2022, the 13-month capped rental period was met on April 24, 2023. Maximus
overturned the Plans denial stating the bed is medically necessary. The Plan requested a reopen and noted the
issue was not medical necessity, but the fact that per Medicare rules, the rental cap had been reached.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan says there is a 13-month rental cap for durable medical
equipment such as a hospital bed. The records show your rental began on March 22, 2022, which meant the
rental capped on April 24, 2023. This was not a medical necessity denial, but a denial based on the Medicare
rules for rented items. Therefore, we decided that the Plan does not have to provide continued coverage for a
hospital bed.