Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis.  
You asked the Plan to pre-approve Lucentis. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Lucentis. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has central retinal artery occlusion of the left eye. The documentation does not support that 
the enrollee has tried and failed bevacizumab. The documentation does not support that bevacizumab would 
likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99356 for date of service October 21, 2022. 
 
You asked the Plan to pay for procedure code 99356. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code at issue is not supported. 
 
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, the CPT Code Manual definition of code 99356 is prolonged service in the inpatient or observation 
setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for 
inpatient or observation Evaluation and Management service). 
 
We find that CPT code 99356 is not supported in the medical record. Specifically, the code definition is time-
based, and the records submitted for review do not document the total time spent providing the services 
described by this code. Based on this information, we decided that Medicare rules for coverage of procedure code 99356 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99356 for date of service October 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital inpatient or observation care, per day, for the 
evaluation and management of a patient (99223) and subsequent hospital inpatient or observation care, per, day 
for the evaluation and management of a patient (99233) provided on January 12, 2023, to January 17, 2023. 
 
You asked the Plan to pay for hospital inpatient care. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says codes 99223 and 99233 are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We asked our coder 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 hospital inpatient care. Our reviewer says that the service 
does not meet criteria for payment on this claim. Our reviewer found there is no admitting note to support the 
99233, and therefore, 99233 is not able to be billed. If there was an admitting note for the enrollee, the progress 
notes for the 99233 is missing elements of the note to bill a level of service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hospital inpatient care have not been met. Therefore, we decided that the Plan 
does not have to pay for initial hospital inpatient or observation care, per day, for the evaluation and 
management of a patient (99223) and subsequent hospital inpatient or observation care, per, day for the 
evaluation and management of a patient (99233) provided on January 12, 2023, to January 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

We decided the Plan does not have to provide coverage for hyalgan injections for both knees for the enrollee.
You asked the Plan to provide coverage for this treatment for the enrollee. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not use the correct Medicare regulations.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of injection. Based on the LCD for this type of injection, the enrollee must have failed conservative therapy. The medical records submitted clearly show the enrollee was non-compliant with the provided home therapy exercise program. Medicare coverage criteria were not met. Therefore, we decided that the Plan does not have to provide coverage for hyalgan injections for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on January 11, 2023.

You asked the Plan to waive the copayment for ambulance services. You say that you say that you never had a cost share for this service and does not feel like they should be responsible for this cost share. 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 $125 copayment for ambulance services.

You have been asked to pay a $125 copayment for ambulance services. 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 ambulance services provided on January 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the requested service to be approved so that you can receive care to get better and return home. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare criteria for LTACH services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to a lower level of 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the capsulectomy periprosthetic breast (1937150) received 
on April 28, 2023, 
 
You asked the Plan to pay for the capsulectomy periprosthetic breast . You say that the service should be 
covered. The Plan denied your request. The Plan says the Medicare allowed amount has been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the capsulectomy periprosthetic breast  have not been met. Specifically, the record indicates that 
the Plan has paid the Medicare allowed amount for this service. A Medicare provider should accept the 
Medicare allowed amount as payment in full. In this case, the Plan is not responsible for paying the balance 
that remains after the Medicare allowed payment. Therefore, we decided that the Plan does not have to pay for 
the capsulectomy periprosthetic breast (1937150) received on April 28, 2023,
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implantable joint device (C1776) provided on December 
20, 2022. 
 
You asked the Plan to pay for C1776. You say that this should be reimbursed. The Plan denied your request. 
The Plan says code C1776 is not supported. 
 
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, the CPT Code Manual definition of code C1776 is joint device (implantable). 
 
We asked our coder 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 C1776. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the procedure report does not include documentation of implantable 
joint device. This service was not found in the medical record.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of C1776 have not been met. Therefore, we decided that the Plan does not have to 
pay for an implantable joint device (C1776) provided on December 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the actigraphy testing (95803) provided on April 17, 2023. 
 You asked the Plan to pay for the actigraphy testing. The Plan denied your request. The Plan says prior 
authorization denied appropriately as services are available in-network. The Plan also says that the medical 
information does not support the need for an authorization to a non-plan provider. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Specifically, the facility this service was 
provided at is an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the 
actigraphy testing (95803) provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 17, 2022 
 
You asked the Plan to pay for dental services. You say that the claim was not submitted until the enrollee's 
dentures fit. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for dental services was not filed until April 19, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for dental services provided on March 17, 2022
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for azathioprine tablets under the Medicare Part B benefit.
You asked the Plan to provide coverage for azathioprine tablets under Medicare Part B. You say that this drug is medically necessary. The Plan denied your request. The Plan says in this case, this drug is prescribed for systemic lupus, which is not covered under Medicare Part B for self-administered drugs.
Maximus overturned the Plans denial stating this drug is an immunosuppressive which is covered as a self-administered drug under Medicare Part B. The Plan requested a reopen and stated that Maximus did not consider that the diagnosis for treatment is not for use as an immunosuppressive.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B due to the diagnosis of system lupus. This drug may be covered as a self-administered drug under your Medicare Part D carrier. Therefore, we decided that the Plan does not have to provide coverage for azathioprine tablets under the Medicare Part B benefit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on November 30, 2022 (D7210).
You asked the Plan to pay for these services. You say that these were not normal dental services and should be covered by the Plan. The Plan denied your request. The Plan says the records show you broke a tooth while eating seafood and sought treatment from your dentist and an oral surgeon for treatment. Maximus overturned the Plans denial for a lack of medical records. The Plan requested a reopen and stated that medical records were requested and provided the office notes for review.
The Plan is correct in this case. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided are not among those dental services covered under this benefit. These were not non-routine dental services. These were not dental services provided due to severe jaw injury, radiation treatment or physical condition requiring these services to allow a medical treatment.
Therefore, we decided that the Plan does not have to pay for dental services provided on November 30, 2022 (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 08, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were 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 subsequent nursing 
facility care provided on June 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Dex Com 7 continuous glucose monitor (Dex Com 7) for the enrollee.
You asked the Plan to provide coverage for a Dex Com 7. . You say that the Dex Com 7 is medically necessary for the enrollee. The Plan denied your request. The Plan says the records show the enrollee's current Dex Com 6 is operational and does not require replacement. Maximus overturned the Plan denial for lack of information in the case file. The Plan requested a reopen and provided the required documentation. The Plan notes that a continuous glucose monitor is replaced every 365 days unless it is damaged. The claim records provided with the reopen show you were issued the Dex Com 6 on December 13, 2022. Therefore, the enrollee is not eligible for replacement until December 14, 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. The enrollee's contract with the Plan clearly says that this type of device is covered once every 365 days.
The records show the enrollee's device was operable on the date of the appeal and was less than a year old. Therefore, we decided that the Plan does not have to provide coverage for a Dex Com 7 continuous glucose monitor (Dex Com 7) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on January 08, 
2023. 
 
You asked the Plan to waive the copayment for emergency care. 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 $125 
copayment for emergency care. 
 
You have been asked to pay a $125 copayment for emergency care. This item/service falls within the 
emergency care 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. However, since the allowed amount is less than the standard copayment, you only owe $100. Therefore, 
we decided that the Plan does not have to waive the copayment for emergency care provided on January 08, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 61781 billed for date of service December 
15, 2022. 
 
You asked the Plan to pay for procedure code 61781. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 61781 is 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 61781 has a status indicator of N on the Physician Fee Schedule. This means that 
procedure code 61781 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 61781 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 61781 billed for date of service December 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS) supplies billed to the enrollee on October 9, 2022.
You asked the Plan to pay for these supplies. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that it has been found in the claim history that this provider has been submitting claims for the TENS unit (E0730 RR KX) indicating this is a rental item. Per Local Coverage Article A52520, during the rental of a TENS unit, supplies for the unit are included in the rental allowance; there is no additional allowance for items such as electrodes, lead wires, and batteries. Since the provider is renting the TENS Unit to the member the provider should not bill for supplies as stated in the LCD A52520.
It is also noted that the provider has billed the plan for 6 units for code A4595 (Electrical stimulator supplies, 2 lead, per month). Medicare guidelines state separate allowance will be made for replacement supplies when they are reasonable and necessary and are used with a covered TENS. The usual maximum utilization is: 2 TENS leads - a maximum of one unit of A4595 per month and 4 TENS leads - a maximum of two units of A4595 per month. The provider submitted the claim for 6 units A4595 which is over the maximum allowed.
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 cannot be paid as billed due to the unit being a rental item and due to an error billed with the number of leads provided. Therefore, we decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS) supplies billed to the enrollee on October 9, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99309 and 90833 billed for date of service 
April 25, 2023.  
 
You asked the Plan to pay for procedure codes 99309 and 90833. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the codes are not covered. 
 
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 99309 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 codes 99309 and 90833 have not been met. 
 
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, the CPT Code Manual definition of code 90833 is psychotherapy, 30 minutes with patient when 
performed with an evaluation and management service (List separately in addition to the code for primary 
procedure). 
 
We find that CPT code 90833 is not supported in the medical record. Specifically, this is an add-on code and is 
not supported because the primary procedure code is not supported. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 99309 and 90833 billed for date 
of service April 25, 2023.