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

We decided the Plan has to pay for SNF care provided March 16, 2022, to April 11, 2022.
You asked the Plan to pay for this SNF care. You say that the enrollee paid up front for these services and they should have been paid by the Plan. The Plan denied your request. Maximus upheld the Plans denial; however, this was done in error.
Additional information received by Maximus shows an Administrative Law Judge (ALJ) reviewed the issue for coverage of SNF services. The ALJ found that the enrollee met all criteria for coverage of SNF services and issued a fully favorable letter to the enrollee. This hearing occurred on August 31, 2022 under OMHA appeal number. As a result of the ALJ's decision, the Plan issued a letter stating that the enrollee was not financially liable for the SNF services they received. However, as the enrollee paid upfront for these services, the Plan is required to reimburse the enrollee for the services approved by the ALJ for payment. The only reason the Plan shows no liability for the enrollee from the provider is because the enrollee paid the bill.
The issue of medical necessity for the SNF services had already been adjudicated by the ALJ before the Maximus decision. The ALJ directed the Plan to pay for the SNF services. It appears this has not been done. The Plan is basing its current denial on lack of medical necessity and not on any other contractual or other administrative point. As the issue of medical necessity had already been settled by the ALJ, the Plan should have complied with the ALJ's decision and should have reimbursed the enrollee for the services rendered which were paid out of pocket. The Plan has an obligation to comply with the ALJ's decision. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) care provided to the enrollee from March 16, 2022, to April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311) for the enrollee.
You asked the Plan to pre-approve an electronic connection. You say that the item is medically necessary. The Plan denied your request. The Plan says that the item is not medically necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic connection. Our Medical Director states that the documentation does not support that the enrollee had a covered indication for the requested electronic connection (E2311) and was medically reasonable and necessary for the enrollee in this case. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of an electronic connection.
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 electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance charged for the bebtelovimab injection and post-administration monitoring provided on September 11, 2022.
You asked the Plan to waive this coinsurance. You say that you do not believe this is correct as you were not charged in the past. 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 stated that Maximus did not apply the correct Medicare allowed amount for 2022. The Plan noted that the Medicare allowed amount for code M0222 was $334.31 and 10% coinsurance is $33.43. The Medicare allowed amount for code Q0222 is $2394.00 and 10% coinsurance is $239.40.
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 10% coinsurance for bebtelovimab injection and post-administration monitoring. 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 charged for the bebtelovimab injection and post-administration monitoring provided on September 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulator supplies billed to the enrollee for September 13, 2022.
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. The Plan says the records provided do not support the services billed. Maximus overturned the Plans denial. The Plan requested a reopen and noted that there is not documentation submitted by the provider to show the enrollee was contacted prior to shipment.
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 records do not show the enrollee requested the refill or was contacted prior to the refill. Medicare rules for coverage of this claim have not been met.
Therefore, we decided that the Plan does not have to pay for electrical stimulator supplies billed to the enrollee for September 13, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on September 16, 2022.
You asked the Plan to pay for this testing. 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 noted that while a unique identifier was billed, code "ZBBLD" is not listed as a covered code for the MoIDX program.
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 unique test identifier code or "Z" code reported is not a valid code. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on September 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) of the lower extremities
(73700) for the enrollee.
You asked the Plan to pre-approve a CT. You say that this is medically necessary. The Plan denied your
request. The Plan says that a face-to-face clinical evaluation is required, detailed history needed, and relevant
lab tests needed.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a CT of the lower
extremities. Our Medical Director states that the computer-assisted musculoskeletal surgical navigation, such
as the requested MAKOplasty, is considered experimental and investigational for knee arthroplasty because
there is insufficient evidence that it improves surgical outcomes. Further long-term data is required to
determine the effectiveness of newer robotic systems. There is insufficient data available at this time to support
that the requested CT scan is medically reasonable and necessary for the enrollee in this case. Our physician
reviewer found that the enrollee's condition does not meet criteria for coverage of a CT scan.
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 CT have not been met. Therefore, we decided that the Plan does not have to
pre-approve a computed tomography (CT) of the lower extremities (73700) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a wound PCR panel (87798, 87481) provided March 9, 2023.

You asked the Plan to pay for the laboratory service. You say that please see the attached records for appeal and reconsideration. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim.

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, this was a panel that was not billed with a single panel code as required. A panel cannot be unbundled and billed as individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for a wound PCR panel (87798, 87481) provided March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right shroud fender (K0108), left shroud fender 
(K0108), shroud module kit (K0108), and back cane hardware kit (K0108). 
 
You asked the Plan to pre-approve the shroud fenders, shroud module kit, and back cane hardware kit. You say 
that the enrollee has useful life left in their chair if the repairs are made. The Plan denied your request. The Plan 
says these items do not serve a medical purpose. The Plan also says that this cannot be covered as it is not 
reasonable and necessary per Medicare criteria. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a right shroud fender (K0108), left shroud fender (K0108), 
shroud module kit (K0108), and back cane hardware kit (K0108).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 84481 billed for date of service January 11, 2023.
 
You asked the Plan to pay for procedure code 84481. You say that you disagree with the denial. The Plan denied your request. The Plan says payment for code 84481 is bundled into payment for code 84480.

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 84481 is a column II code to column I code 84480 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met.

We have confirmed that code 84480 is a column II code to column I code 84436 with a modifier indicator of 0. The column II code is therefore not payable. 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 84481 billed for date of service January 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) month continued use of a noninvasive 
ventilator (NIV) (E0466). 
 
You asked the Plan to pre-approve continued use of a NIV. You say that without the ventilator the enrollee will 
not survive. The Plan denied your request. The Plan says the request for continued use of the ventilator is not 
medically reasonable and necessary. 
 
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. 

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 continued use of a NIV. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee has COPD and 
congestive heart failure with recurrent hospitalizations. Arterial blood gases (ABGs) are consistent with 
recurrent acute on chronic hypercarbic respiratory failure. The enrollee has had a home ventilator since March 
2022.  However, device download indicates the enrollee is not consistently using the device more than 4 
hours/day. There is no diagnosis of thoracic restrictive disease or neuromuscular disease.  There are no 
pulmonary function tests to assess the severity of the COPD. The enrollee is on a chronic narcotic. There is no 
evidence in the record that bilevel positive airway pressure (BiPAP) with average volume-assured pressure 
support (AVAPS) has been tried and failed as an outpatient.  Medicare does not cover a home ventilator when 
used at settings that can be provided with BiPAP.  The enrollee has the current device for 3 months, which 
allows time for transition to BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a NIV have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nine (9) month continued use of a noninvasive ventilator (NIV) (E0466).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech therapy provided on May 02, 2022, to May 31, 2022. 
 
You asked the Plan to pay for speech therapy. You say that you are appealing the claim payment denial. 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 speech therapy provided 
on May 02, 2022, to May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve High frequency chest wall oscillation devices 
(HFCWO) (E0483). 
 
You asked the Plan to pre-approve HFCWO. 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 follows Medicare rules. Medicare rules say that high frequency chest wall oscillation devices 
(HFCWO) (E0483) are covered for beneficiaries who meet specific criteria. 
 
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 HFCWO. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is insufficient documentation that the 
enrollee has met the coverage criteria for a high frequency chest wall oscillation device. The enrollee does not 
have a diagnosis of cystic fibrosis, bronchiectasis, or sufficient clinical documentation of a neuromuscular 
disease with well-documented failure of standard treatments to adequately mobilize retained secretions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HFCWO have not been met. Therefore, we decided that the Plan does not have 
to pre-approve High frequency chest wall oscillation devices (HFCWO) (E0483).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays, a cleaning, filling, and extensive oral 
evaluation (D0230, D2392, D0220, D1110, D0160) provided on March 9, 2023, to March 15, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for 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 the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. This benefit does not include extensive 
oral evaluations. 
 
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. 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Additionally, extensive oral evaluations are not 
among those covered under this benefit, regardless of the providers network status. Therefore, we decided that 
the Plan does not have to pay for intraoral x-rays, a cleaning, filling, and extensive oral evaluation (D0230, 
D2392, D0220, D1110, D0160) provided on March 9, 2023, to March 15, 2023, by an out-of-network (OON) 
provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 73562 provided on April 27, 2022.  
 
You asked the Plan to pay for procedure code 73562. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, we find that the Plan has not provided enough evidence to support 
the denial of payment for procedure code 73562 based on Medicare criteria. The Plan has provided no 
Medicare regulations or guidelines to support the denial of payment. Therefore, we decided that the Plan has to 
pay for procedure code 73562 provided on April 27, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for TissueCypher Barrett's esophagus assay (0108U) provided 
on January 31, 2023.  
 
You asked the Plan to pay for TissueCypher Barrett's esophagus assay. You say that this test is covered by 
Medicare. The Plan denied your request. The Plan says the clinical value and effectiveness of TissueCypher 
Barrett's esophagus assay have not been demonstrated in the peer-reviewed literature. 
 
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 pay for TissueCypher Barrett's esophagus assay. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found TissueCypher is not endorsed by national clinical guidelines as standard of 
care and does not meet criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TissueCypher Barrett's esophagus assay have not been met. Therefore, we 
decided that the Plan does not have to pay for TissueCypher Barrett's esophagus assay (0108U) provided on 
January 31, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on February 25, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
emergency medical technician checked your vitals and since you felt fine you decided to go home versus being 
transported to the hospital. The Plan denied your request. The Plan says these services are not a covered 
benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 25, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on February 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
March 06, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you disagree with 
the 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 $295 
copayment for ambulance services. 
 
You have been asked to pay a $295 copayment for the ambulance transportation. This item/service falls within 
the 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 transportation provided on March 06, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Optichamber Diamond provided on April 26, 2023. 
 
You asked the Plan to pay for Optichamber Diamond. You say that you are appealing this denial. 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 Optichamber Diamond 
provided on April 26, 2023.