Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit provided on December 
06, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that this was only a 3 minute phone 
call. 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 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for the specialist visit. This item/service falls within the 
physician/practitioner services, including doctors 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 copayment for the specialist visit provided on December 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 18, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting the submitted documentation be 
reviewed. 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 office visit provided on 
August 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 9, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-precision abutment and semi-precision 
attachment (D6192, D6191). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as 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 Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted with the Plans authorization on February 4, 
2023. Therefore, we decided that the Plan does not have to pre-approve a semi-precision abutment and semi-
precision attachment (D6192, D6191).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 21, 2022.
You asked the Plan to pay for procedure code 76641. You say that the records support the performed procedure. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service July 29, 
2022. 
 You asked the Plan to pay for procedure code 93042. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 
93010. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93042 
is a column II code to column I code 93010. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93042 billed for date of service July 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the IV therapy and drugs provided from 
January 25, 2023, to January 27, 2023. 
 
You asked the Plan to waive the copayments for the IV therapy and drugs. You say that you were not told 
about the infusion cost. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
 You have been asked to pay 20% coinsurance for the IV therapy and drugs. These items/services fall within the 
Medicare Part B prescription drugs benefit category.  
 
Date of Service Item Allowed Amount  20% Coinsurance 
January 25, 2023 IV therapy $201.41  $40.28  
January 25, 2023 IV therapy $78.80  $15.76  
January 25, 2023 Drugs $1,102.00  $220.40  
January 26, 2023 IV therapy $201.41  $40.28  
January 26, 2023 Drugs $551.00  $110.20  
January 27, 2023 IV therapy $201.41  $40.28  
January 27, 2023 Drugs $551.00  $110.20  
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for the IV therapy and drugs provided from January 25, 2023, 
to January 27, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided to the enrollee on April 4, 2022 and billed under code 88305-26-59.
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 provided additional information. The Plan noted this service was denied as a duplicate to a referring claim billed by same provider for the same date of service.
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 this claim appears to be a duplicate to services previously billed. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for pathology services provided to the enrollee on April 4, 2022 and billed under code 88305-26-59.
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 for the enrollee.
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 stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for transfer to an acute inpatient rehabilitation facility. Based on the medical records provided the complexity of the nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees' medical conditions appear improved on stable outpatient medications with no issues that appear to require a physician's evaluation three or more times per week in a hospital setting.
The medical records provided do not clarify why the enrollee requires an intensive inpatient rehabilitation therapy program. Provided medical records do not explain why the intensive inpatient rehabilitation therapy program is necessary and why therapy at a lower level of care such as in a skilled nursing facility is not appropriate for the patient.
Based on the medical records provided there is concern that the enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility do to her reported decreased endurance and her limited prior level of functioning. Medicare coverage criteria are not met.
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 provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services billed to the enrollee for July 14, 2022, under code 93880 and diagnosis code R53.1 for weakness.
You asked the Plan to pay for this service. You say that this claim should be paid The Plan denied your request. The Plan says the billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted this duplex scan denied because code 93880 was not reported with appropriate diagnosis code. The Plan states that Local Coverage Article A57592 does not include diagnosis code R53.1 (Weakness) in the list of approved diagnosis codes.
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 code. In this case, this claim was not submitted with a valid diagnosis code for the service provided. 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 billed to the enrollee for July 14, 2022, under code 93880 and diagnosis code R53.1 for weakness.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gauze provided on October 14, 2022. 
 
You asked the Plan to pay for gauze. You say that you are requesting the submitted documentation be 
reviewed. 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 gauze provided on 
October 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
October 22, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were only transported 
a few feet and should not have to pay this copayment. 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 $250 
copayment for ground ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance services. This item/service falls within the 
ground ambulance services 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 copayment for the 
ambulance services provided on October 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 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 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 documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 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 continuous glucose monitor (CGM).
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 for the enrollee.
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 stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF services.
The enrollee was a then 66-year-old with a medical history that included heart disease, hypertension, alcohol dependence, anemia, and severe peripheral artery disease, who was admitted to the hospital on December 26, 2022, with influenza A and acute respiratory failure requiring intubation. Vascular surgery was performed on January 12, 2022, as well as amputations of the right first, second, and third toes. The enrollee had multiple wounds. The Hospital Medicine Progress Note dated January 25, 2023, documented that the enrollee was medically ready for discharge, with placement pending in a skilled nursing facility. The Plan is correct in this case. The clinical documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy procedure provided on 
January 12, 2023. 
 
You asked the Plan to waive the copayment for the endoscopy procedure. You say that you say that the 
copayment is too high and you are on a fixed income. 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 $170 
copayment for outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $170 copayment for the endoscopy procedure. This item/service falls within the outpatient surgery, including services provided at ambulatory surgical centers 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 copayment for the endoscopy procedure provided on January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 10, 2022. 
 
You asked the Plan to pay for an office visit. You say that this 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 an office visit provided 
on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound debridement procedure provided on October 6, 
2022, by an OON provider. 
 
You asked the Plan to pay for the wound debridement procedure. You say that this service was medically 
necessary. The Plan denied your request. The Plan says that this service is not covered when performed by an 
out-of-network provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that podiatry services are not covered when provided by an out-of-network provider. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the wound debridement procedure provided on 
October 6, 2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital stay provided on October 28, 2021, to 
November 14, 2021. 
 
You asked the Plan to pay for inpatient hospital stay. You say that you believe the services are 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 inpatient hospital stay 
provided on October 28, 2021, to November 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Prodigy Autocode Blood Glucose Monitoring System for the enrollee.
You asked the Plan to pre-approve Prodigy Autocode Blood Glucose Monitoring System from a retail pharmacy. You say that this equipment is medically necessary for the enrollee. The Plan denied your request. The Plan says there is no documentation to show why the enrollee cannot use an approved Medicare durable medical equipment provider instead of a retail pharmacy.
Maximus overturned the Plans denial stating the equipment was medically necessary. The Plan requested a reopen and stated that the issue was not medical necessity but the fact that the equipment was requested from a non-approved pharmacy with no specific reason as to why.
The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that if their supplier in your area does not carry a particular brand or manufacturer, you may ask them if they can special order it for you. The retail pharmacy in this case is not a network DME provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items to be purchased from a retail pharmacy. Therefore, we decided that the Plan does not have to pre-approve a Prodigy Autocode Blood Glucose Monitoring System for the enrollee.