Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for a thyroid-hormone assay (84443) provided on June 27, 2023. 
 
You asked the Plan to pay for a thyroid-hormone assay. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that that thyroid testing may be reasonable and necessary 
to: 
1. Distinguish between primary and secondary hypothyroidism; 
2. Confirm or rule out primary hypothyroidism; 
3. Monitor thyroid hormone levels (for example, patients with goiter, thyroid nodules, or thyroid cancer); 
4. Monitor drug therapy in patients with primary hypothyroidism; 
5. Confirm or rule out primary hyperthyroidism; and 
6. Monitor therapy in patients with hyperthyroidism. 
 
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 a thyroid-hormone assay. Our reviewer says 
that a thyroid-hormone assay is medically reasonable and necessary in this case. Our physician reviewer found 
that in a patient with cardiac-rhythm abnormalities, a thyroid-hormone assay is reasonable to rule out an over-
active thyroid or primary hyperthyroidism. 
 
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 thyroid-hormone assay have been met. Therefore, we decided that the Plan 
has to pay for a thyroid-hormone assay (84443) provided on June 27, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for multiple vitamins provided on September 22, 2023. 
 
You asked the Plan to pay for multiple vitamins. You say that you are requesting reconsideration for 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 multiple vitamins 
provided on September 22, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837) provided on September 30, 2023. 
 
You asked the Plan to pay for the psychotherapy (90837). You say that the service was medically necessary. 
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 psychotherapy 
(90837) provided on September 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic therapy 
 
You asked the Plan to pre-approve aquatic therapy. You say that you have chronic lower back pain and you 
have been going to physical therapy. You say that you fell and have a compression fracture in your back and 
that you have unbearable, chronic pain. The Plan denied your request. The Plan says the member has already completed 6 sessions of physical therapy and was discharged with good compliance. The member was noted 
with no difficulty with walking and standing. The member already reached his maximum potential with regards 
to his ambulation and mobility and would no longer benefit from aquatic therapy sessions. 
 
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 aquatic therapy. Our reviewer says that 
the requested aquatic therapy is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that aquatic therapy is medically necessary for individual with functional loss (decreased 
strength, range of motion or mobility) due to a disease, injury or surgery and when an aquatic environment is 
determined to be more effective or advantageous over land-based therapy. Aquatic therapy allows for exercise 
in a gravity-reduced, non-weight-bearing environment under the management of a physical therapist.  
The documentation does not support that you require aquatic therapy. There is no reason clearly documented 
that you cannot participate in the land-based physical therapy. Additionally, the documentation indicates that 
you have improved physical functioning and can continue with a home exercise program. Additional formal 
physical/aquatic therapy is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aquatic therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve aquatic therapy
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for home health services to include occupational
and physical therapy.

You asked the Plan to provide coverage for home health care to include occupational and physical therapy. The
Plan approved the skilled nursing services and denied the therapy services. Maximus partially overturned this
denial in error as Maximus decided on the skilled services that were already approved.

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 the
item/service at issue. Our physician reviewer found you were noted to be medically stable. You were educated
regarding medications and have not recently been hospitalized. The medical records provided at the time of the
appeal show you required very little assistance (contact guard assistance) with mobility and daily activities and
your level of mobility has not significantly changed with physical therapy.

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 item/service at issue have not been met. Therefore, we decided that the Plan
does not have to provide coverage for occupational and physical therapies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 12 physical therapy (PT) visits.

You asked the Plan to pre-approve the therapy services. You say that your physicians are recommending
additional therapy visits to treat your knee pain until your surgery. The Plan denied your request. The Plan says
that the additional therapy visits are not medically necessary.

Our Medical director looked at the case file and the reopen request. At issue is coverage for an additional 12
physical therapy (PT) visits. Our Medical Director states that the available clinical documentation does not
support that the unique skills of a professional therapist are required to safely and effectively provide treatment,
that the services can be safely and effectively performed only by a therapist, or for physical therapy and
occupational therapy, by or under the supervision of a therapist. It is not clear that the requested additional PT
visits are medically reasonable and necessary for the enrollee in this case. Our Medical Director found that
your condition does not meet criteria for coverage of an additional 12 physical therapy (PT) visits.

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 therapy services have not been met. Therefore, we decided that the Plan
does not have to pre-approve an additional 12 physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for inpatient hospital care provided from July
23, 2023, to July 26, 2023.

You asked the Plan to waive this cost share. The Plan denied your request. The Plan says this cost sharing was
charged correctly. Maximus upheld the original decision however there were errors in the contract language
quoted so the case was reopened. The Plan states in 2023, there was a deductible requirement of $150, annual
coinsurance/deductible maximum of $500, and a total out of pocket maximum for medical copay-based
services of $1,500.

The Plan contract also states Inpatient Hospital Care is covered in-network with a 10% coinsurance of the
approved amount, after you meet your annual deductible. The Plan notes at the time this claim was received
and processed, you had met the following: Copay - $137.79. Coinsurance - $350. Deductible - $150. The order
in which cost share was applied can be determined by the paid date column on the Explanation of Benefits
(EOB) Summary that is included in this case packet. Based on this information, the Plan upheld the initial
processing of the claims on November 10, 2023

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 (such as copayments, deductibles, and coinsurance). Your contract with the Plan
clearly says in 2023 there was a deductible and then a 10% coinsurance that applied to inpatient care.
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 waive the cost share for inpatient admission provided from July 23, 2023, to July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the crown (D2740) and core buildup (D2950) for tooth #14 provided on
June 27, 2023.

You asked the Plan to pay for the crown and core buildup. You say that these services should be covered as
you disagree with the denial. The Plan denied your request. The Plan says that the services denied correctly as
they were not medically necessary. Maximus overturned the Plan's denial based on lack of information. The
Plan requested a reopening and provided medical records for review.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a crown and core
buildup. Our Medical Director states that the clinical documentation supports that the crown and core buildup
were necessary for tooth #14, as more than half the tooth was damaged due to decay or injury and had a
reasonable expected long-term outcome. Our Medical Director found that your condition met criteria for
coverage of the crown and core buildup.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the crown and core buildup have been met. Therefore, we decided that the Plan
has to pay for the crown (D2740) and core buildup (D2950) for tooth #14 provided on June 27, 2023.

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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for code 99284 billed to the enrollee for November 15, 2022.

You asked the Plan to pay for code 99284. 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 noted that
Maximus did not apply the correct billing criteria.

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 medical records provided do not support the billing of code 99284.
The required components for moderate to severe complex treatment with physical examination are not reflected
in the medical records provided. Medicare rules for payment of code 99284 were not met. Therefore, we
decided that the Plan does not have to pay for code 99284 billed to the enrollee for November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing provided on May 9, 2023. 
 
You asked the Plan to pay for the PrismRA testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that PrismRA testing is only covered for certain 
indications. 
 
We looked at the file and Medicare rules. Review of the file shows that the documentation does not show that 
the enrollee is an adult with a confirmed diagnosis of moderately to severely active rheumatoid arthritis. 
Additionally, the documentation submitted does not show that the enrollee has a history of failure, 
contraindication, or intolerance to at least one first-line therapy for the treatment of RA (i.e., conventional 
synthetic disease-modifying anti-rheumatic drugs (csDMARDs)) despite adequate dosing. This means the 
enrollee did not meet criteria for the testing rendered. Based on this information, we decided that Medicare 
rules for coverage of the PrismRA testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the PrismRA testing provided on May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to return payment for the inpatient services provided from October 29, 
2022, to December 14, 2022, in the amount of $37,446.17. 
 
You asked the Plan to return payment for the inpatient services in the amount of $37,446.17. You say that the 
inpatient services should be paid because they were billed accurately. The Plan denied your request. The Plan 
says the inpatient services are denied because they are not supported in the provided documentation.  
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. We have confirmed no medical records were provided to support the 
inpatient services. The case file contains proof that these records were requested multiple times by the Plan, but 
this request was refused. Without medical records we are unable to confirm if the inpatient services denied by 
the Plan are supported or not. Based on this information, we decided that there is insufficient information in the 
record to determine if Medicare rules for coverage of the inpatient services totaling $37,446.17 have been met. 
Therefore, we decided that the Plan does not have to return payment for the inpatient services provided from 
October 29, 2022, to December 14, 2022, in the amount of $37,446.17.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on July 8, 2023.

You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not enrolled with Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on July 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for kyphoplasty. 
 
You asked the Plan to pay for kyphoplasty. You say that the fracture caused the enrollee severe pain, and she 
has met all the requirements to get the kyphoplasty. The Plan denied your request. The Plan says this does not 
meet the criteria for approval. 
 
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 kyphoplasty. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the cause of pain is not clear. There is no 
imaging showing only Modic changes without facet degenerative disc disease or stenosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pay for kyphoplasty.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for procedure codes 36200 and 37237 billed for date of service April 19, 
2023. 
 
You asked the Plan to pay for the billed services. You say that no issues were identified with the billed codes. 
The Plan denied your request. The Plan says that the codes are not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. Plans must pay for a medical service or item if regular Medicare would pay 
for it in this case. The Plan cited coding references in their decision to deny services. The Plan did not 
provide Medicare rules that show the services at issue were not payable in this case. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. Therefore, we decided that the Plan has to pay for procedure codes 36200 and 37237 billed for date of 
service April 19, 2023.  
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the $10 copayment charged for an out-of-network 
bone density (DXA) scan provided on June 20, 2023.

You asked the Plan to waive the cost share for this service. We note the Plan removed the $9.10 copayment.
The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus upheld the Plans
denial for the incorrect copayment,

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 $25
copayment for bone mass measurement. In this case you are being charged less than your normal copayment.
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 $10 copayment charged for an out-of-network bone density
(DXA) scan provided on June 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox for the enrollee.

You asked the Plan to pre-approve Botox. You say that this is medically necessary. The Plan denied your
request. The Plan says that the enrollee does not have a covered diagnosis. Maximus overturned the Plan's
denial based on medical necessity. The Plan requested a reopening and stated that this was not a medical
necessity denial and that this was denied because the enrollee does not have a covered condition. The Plan is
correct in this case. Medicare rules say that Botulinum toxin is covered for certain spastic conditions.

We looked at the file and Medicare rules. According to Medicare rules the enrollee's diagnosis of Dyskinesia
of esophagus (K22.4) is not a covered diagnosis. Based on this information, we decided that Medicare rules for
coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox
for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the upgraded pylon and vacuum socket (VASS
system) for the enrollee.

You asked the Plan to provide coverage for the these prosthetic accessories. You say that at the time of the
appeal, this prosthetic equipment was medically necessary. The Plan denied your request. The Plan says
Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen
and stated that Maximus did not apply the correct criteria. The Plan noted that the requested VASS (L5781)
prosthetic component(s) exceeds the enrollee's needs. The Plan notes the VASS system is also considered
experimental and investigational and is not covered by Medicare.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. Medicare does not cover prosthetic equipment that
exceeds the enrollees needs. There is insufficient documentation in the medical records to show the requested
prosthetic equipment is medically necessary for the enrollee. Therefore, we decided that the Plan does not have
to provide coverage for the upgraded pylon and vacuum socket (VASS system) for the enrollee.