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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 10, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the tests should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on January 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 23430-59 billed for date of service February 
1, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the use of the modifier is not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 The medical records provided do not show that the service billed with the -59 modifier was a distinct 
procedural service. The records do not indicate the service at issue was a separate procedure not ordinarily 
encountered on the same day. Based on this information, we decided that Medicare rules for coverage of 
services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 23430-59 billed for date of service February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that you are appealing the denial for the 
Intracept procedure. The Plan denied your request. The Plan says that the Intracept procedure is considered 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) showing only modic changes 
without foraminal stenosis or facet degenerative joint disease. The cause of back pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0821). 
 
You asked the Plan to pre-approve a power wheelchair. You say that an electric wheelchair will help you get 
around. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that you do not require a power 
wheelchair to perform your MRADLs in your home. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 2 power wheelchair (K0821).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share for therapeutic radiology services and lab services provided on March 1, 2022, to April 1, 2022.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that the cost share is determined by each individual claim submitted by the provider. The documentation shows the billed amount is $2393.01 and not the amount calculated by Maximus.
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 that you must pay a $10 copayment for lab services and a 20% coinsurance for therapeutic radiology services. You have been asked to pay the correct amount for each service 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 or reduce the cost share for therapeutic radiology services and lab services provided on March 1, 2022, to April 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a freestyle libre 14-day sensor continuous glucose 
monitor (CGM).  
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a freestyle libre 14-day sensor continuous glucose monitor 
(CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the left ankle brace (L1971), and gel heel cup (L3170) provided to the enrollee on April 1, 2022.
You asked the Plan to pay for the left ankle brace and gel heel cup. You say that the items were medically necessary for the enrollee. The Plan denied your request.
The Plan says the documentation requirements have not been met. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that we did apply the correct criteria.
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 records provided do not mention the need for an ankle brace and heel cup or any condition that requires these items. 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 left ankle brace (L1971), and gel heel cup (L3170) provided to the enrollee on April 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs wound care because having 
several wounds, on behind left thigh, one on left lower leg and right ankle, and is diabetic.  The Plan denied 
your request. The Plan says the enrollee's records do not show the need for skilled services daily nor require 
skilled services on an inpatient basis. Services can safely be received at a different setting, home with home 
health, in residential care, or home with close follow-up with a physician 
 
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 skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Orthovisc injection. 
 
You asked the Plan to pre-approve an Orthovisc injection. You say that you do not agree with the denial for an 
Orthovisc injection. The Plan denied your request. The Plan says you do not meet all of the Medicare 
requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that various Hyaluronan preparations 
(viscosupplementation) for intra-articular injections of the knee are considered reasonable and necessary when 
there has been a trial and failure or contraindication of at least 3 months of conservative therapy. 
 
We looked at the file and Medicare rules. The documentation does not show there has been three months of 
conservative therapy. Based on this information, we decided that Medicare rules for coverage of an Orthovisc 
injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an Orthovisc 
injection.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDX-SCC test provided to the enrollee on October 6, 2022.
You asked the Plan to pay for the testing. You say that the claim should be paid the Medicare established rate. The Plan denied your request. The Plan says that this is not covered.
Medicare rules say that molecular diagnostic laboratory tests are subject to the MolDX application, assessment, and approval process.
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDX-SCC test provided to the enrollee on October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 provided on December 21, 2022, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure code 99204 provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide OON care. 
 
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 procedure code 99204 provided on December 21, 
2022, 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 99100 billed for date of service August 17, 
2022. 
  You asked the Plan to pay for procedure code 99100. You say that the documentation should be reviewed and 
the claim processed for payment. The Plan denied your request. The Plan says procedure code 99100 is 
considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for office visits on January 19, 2023, to 
February 02, 2023.  
 
You asked the Plan to waive the coinsurance for office visits. You say that this is in-network service. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
 
 
 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40% 
coinsurance for out-of-network provider and professional services at primary care providers office and 
specialists office. Covered services include medically necessary medical care or surgery services furnished in 
a physicians office, certified ambulatory surgical center, hospital outpatient department, or any other location 
and consultation, diagnosis, and treatment by a specialist. For date of service January 19, 2023, the provider 
billed in the amount of $230 and the allowed amount is $197.10 for the service. $197.10 x 40% = $78.84. For 
date of service February 02, 2023, the provider billed in the amount of $305 and the allowed amount is $140.90 
for the service. $140.90 x 40% = $56.36. For both dates it's, $78.84 + $56.36 = $135.20. Therefore, results in 
the total cost sharing amount of $135.20. 
 
You have been asked to pay a 40% coinsurance for office visits. This item/service falls within the 
physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for office visits on January 19, 2023, to February 02, 2023.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee from
August 26, 2022, through August 30, 2022, and September 2, 2022, through October 1, 2022.
As an appealing party for the enrollee, you asked the Plan to pay for these services. The Plan denied your
request. The Plan says that the claim submitted by the provider has code errors. The Plan also illuded there was
a transportation issue in their denial letter. Maximus overturned the Plans denial but reviewed for transportation
and not SNF services. Maximus then reopened the file to correct the error.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the Plan unless notice is provided that the services will not be covered.
The Plan follows these rules. These services were SNF services, not transportation, as indicated the Plans
original denial letter. The Plans corrected decision letter does not give specific denial reasons. The case file did
not contain medical records and states this was a coding issue. Coding issues between Par providers and the
health Plan should be resolved internally and do not affect coverage for the enrollee. Services rendered to
enrollees by Plan contract providers are considered by Medicare to be approved services if no notice of noncoverage
is given. The case file contained no medical records and does not show that the Plan provided notice
that these services would not be covered. Therefore, we decided that the Plan has to pay for skilled nursing
facility (SNF) services provided to the enrollee from August 26, 2022, through August 30, 2022, and
September 2, 2022, through October 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network diabetic supplies provided from July 25,
2022, to January 29, 2023, at the in-network rate.
You asked the Plan to pay for these supplies at the in-network rate. You say that you believe your cost share
should be $5 for each. The Plan denied your request. The Plan says this cost sharing was charged correctly.
Maximus agreed with Plan however the case file was reviewed a second time to give more clarity in the
decision. Below is a break down of the actual cost share.
The Plan received a claim for diabetic supplies provided on July 25, 2022, from the out of network provider
and applied a 30% coinsurance in the amount of $81.89.
For supplies provided on August 25, 2022, from the out of network provider, the Plan applied a 30%
coinsurance in the amount of $81.89.
For supplies provided on September 25, 2022, from the out of network provider, the Plan applied a 30%
coinsurance in the amount of $70.38.
For supplies provided on October 26, 2022, from the out of network provider, the Plan applied a 30%
coinsurance in the amount of $70.38.
For supplies provided on November 28, 2022, from the out of network provider, the Plan applied a 30%
coinsurance in the amount of $70.38.
For supplies provided on December 29, 2022, from the out of network provider, the Plan applied a 30%
coinsurance in the amount of $70.38.
For supplies provided on January 29, 2023, from the out of network provider, the Plan applied a 30%
coinsurance in the amount of $70.38.
Each cost share was applied based on the claim submitted from your provider and the Plan contract agreement.
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 30%
coinsurance for out of network diabetic supplies. 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 pay for diabetic supplies provided from July 25,
2022, to January 29, 2023, at the in-network rate.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repair of nasal valve collapse using Latera (an 
absorbable nasal implant). 
 
You asked the Plan to pre-approve the Latera implant. You say that the enrollee has a nasal obstruction that 
includes bilateral alternating nasal obstruction, nasal congestion, mouth breathing, and snoring. You also say 
that the medical records support that this procedure is medically necessary for the enrollee. The Plan denied 
your request. The Plan says the requested procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Latera implant. Our reviewer says 
that the requested Latera implant is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has nasal congestion from rhinitis. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested service. 
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, 
of the requested service. Therefore, the reviewer found that the requested Latera implant 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 the Latera implant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the repair of nasal valve collapse using Latera (an absorbable nasal implant).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo procedure. 
 
You asked the Plan to pre-approve Barostim Neo. You say that this is approved for the enrollee's condition. 
The Plan denied your request. The Plan says there remains an absence of randomized, blinded clinical studies 
examining long-term clinical outcomes to establish the value of Barostim Neo in patient management. 
 
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 Barostim Neo. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient 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 Barostim Neo have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Barostim Neo procedure.