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

 
We decided that the Plan does not have to pre-approve EpiFix-Human Allograft. 
 
You asked the Plan to pre-approve EpiFix-Human Allograft. You say that for two years you have battled a 
severe leg wound unsuccessfully. You say that the pain and infection has been unbearable and a procedure now 
is possible through state-of-the-art stem cell therapies. The Plan denied your request. The Plan says there is not 
enough evidence to show that other amniotic products or bioengineered skin or soft tissue substitutes can 
improve health outcomes for patients with lower-extremity ulcers due to venous insufficiency.  
 
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 EpiFix-Human Allograft. Our reviewer 
says that the requested EpiFix-Human Allograft is not considered medically reasonable and necessary. Our 
physician reviewer found that the medical documentation supports that you are currently suffering with venous stasis ulcerations to the left lower extremity. You admit to having these ulcerations for two years. During a 
medical visit dated August 8, 2023, you were evaluated for left lower extremity ulcerations. The wounds were 
measured and evaluated. The basis of the ulcerations were noted to be fibrotic. Santyl was recommended to be 
applied to these wounds daily. Medicare advises that they pay for items or services that are medically 
reasonable or necessary for the diagnosis or treatment of an illness or injury. These must be safe and effective, 
not mainly for the convenience of the patient or the physician, appropriate in that they are furnished in 
accordance with accepted standards of medical practice for the diagnosis or treatment of the patients 
condition, one that meets but does not exceed the patients medical need, and at least as beneficial as existing 
and available medically appropriate alternatives. In this particular case the medical documentation provided 
does not advise of standardized wound care performed for greater than 30 days. The medical documentation 
does not advise of serial wound debridement, Unna boot dressings to the left lower extremity to alleviate and or 
reduce the lower extremity edema, prolonged Santyl ointment application with standardized dressings, 
offloading of the ulcerative areas, or foam or alginate wound dressings. It does not appear that advanced wound 
applications such as EpiFix is appropriate at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of EpiFix-Human Allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve EpiFix-Human Allograft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Freestyle Kit sensor for the enrollee.

You asked the Plan to provide coverage for a Freestyle Kit sensor. You say that this equipment is medically necessary for the enrollee. The Plan denied your request. The Plan says there were no medical records submitted to support this request. Maximus overturned the Plans denial stating you are a contract provider, and the Plan should make efforts to get records. The Plan requested a reopen and provided documentation to show they requested medical records from you several times with no response.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of a Freestyle Kit sensor have been met. medical records. Therefore, we decided that the Plan does not have to provide coverage for a Freestyle Kit sensor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 You asked the Plan to pre-approve a power scooter. You say that you need the power mobility device. You say 
that your legs give out when walking long distances. You also say that you fell several times going to the bus 
stop. The Plan denied your request. The Plan says the notes do not say you have any trouble with walking when 
doing any activities of daily living. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a power scooter have been met. The 
file does not support that you have a mobility deficit that impairs your participation in MRADLs, your 
condition cannot be improved by a walker, cane or manual wheelchair, nor that you can safely operate the 
PMD being requested. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the hospital bed. You say that you strongly disagree with the notion that a 
fully electric bed is merely a convenience and not a necessity for individuals who are bedridden. The Plan 
denied your request. The Plan says a total electric hospital bed is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric 
hospital bed (E0265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you do not feel like you should pay for this. The 
Plan denied your request. The Plan says your $750 annual dental maximum allowance 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 $750 annual dental maximum allowance was exhausted on date of service arch 6, 2023. Therefore, 
we decided that the Plan does not have to pay for dental services provided on March 24, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound guided biopsy provided on January 25, 2023. 
 
You asked the Plan to pay for an ultrasound guided biopsy. You say that you have not been to this facility and 
did not have this procedure. 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). You did have a procedure on this date, at this hospital, per medical records. Therefore, we decided that the Plan does not have to pay for an ultrasound guided biopsy provided on January 
25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network pacemaker replacement 
procedure provided on January 16, 2023. 
 
You asked the Plan to waive the copayment for an in-network pacemaker replacement procedure. You say that 
you do not believe this copayment is correct. 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 $225 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $225 copayment for an in-network pacemaker replacement procedure. This 
item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
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 an in-
network pacemaker replacement procedure provided on January 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have used this dentist for years. You were 
unaware that they were no longer in-network. 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.  
 
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. Therefore, we decided that the Plan does not have 
to pay for dental services provided on March 8, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF stay provided from November 2, 
2022, to November 30, 2022. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that the enrollee should not have a 
copayment for the SNF stay because they became ill and had to stay longer. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $0 copayment per day for days 1-20 and $188 copayment per day for days 21-100.  The enrollee has been asked to pay a total of $1,692 for the SNF stay ($188/per day x 9 days = $1,692). This 
item/service falls within the skilled nursing facility (SNF) care benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the SNF stay provided from November 2, 2022, to November 30, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided from April 11, 2022, to July 25, 2022.

You asked the Plan to pay for these services. You say that your internist told you to go to this clinic. The Plan denied your request. The Plan says this provider does not take Medicare insurance and does not bill insurance in general. Maximus overturned the Plans denial as plan directed care. The Plan requested a reopen and noted that this type of establishment does not provide emergency services and is not an eligible Medicare provider.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program. Cosmetic procedures and supplements other than those covered by a prescription are not covered. This provider is clearly stated to be a cosmetic and/or weight loss service establishment. While your internist may have recommended their services, there is nothing in the medical records to show your internist made treatment arrangements with the provider. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who is not eligible to accept Medicare payment. Therefore, we decided that the Plan does not have to pay for lab services provided from April 11, 2022, to July 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated back cushion (E2617), expandable controller (E2377), harness (E2313) and electronic connection (E2311) for the enrollee.

You asked the Plan to pre-approve a custom fabricated back cushion, expandable controller, harness and electronic connection. You say that these items are medically necessary. The Plan denied your request. The Plan says that notes do not clearly explain why a prefabricated seating system is not sufficient to meet the member's needs and the enrollee's right upper limb strength and function are adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a custom fabricated back cushion, expandable controller, harness and electronic connection. Our Medical Director states that the available documentation does not clearly explain why a prefabricated seating system is not sufficient to meet the enrollee's seating and positioning needs. The documentation supports that the enrollee's upper extremity strength and function appear to be adequate to operate the power options using their own switches. The documentation is insufficient to demonstrate that an expandable controller, harness, and electronic connection are 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 a custom fabricated back cushion, expandable controller, harness and 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 a custom fabricated back cushion, expandable controller, harness and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated back cushion (E2617), expandable controller (E2377), harness (E2313) and electronic connection (E2311) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental x-rays provided on April 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you did not know this would not be covered, 
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 on date of service April 14, 2023. The Plan 
approved two dental x-rays; the third x-ray has been correctly denied. Therefore, we decided that the Plan does 
not have to pay for the third dental x-ray provided on April 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crown - porcelain/ceramic (D6740) and pontic -
porcelain/ceramic (D6245) provided on December 20, 2022.

You asked the Plan to pay for the crown and pontic. You say that these services were medically necessary. The
Plan denied your request. The Plan says your benefit for the crown has been exhausted and that pontics are not
a covered benefit. Maximus partially overturned the Plan's denial because of insufficient information. The Plan
requested a reopening and stated that the enrollee's benefit for crowns was exhausted. The Plan is correct in
this case. The Plan provided two Explanation of Benefits documents to show that they have provided payment
for 2 crowns for this Plan year. The documentation confirms the Plan paid for one crown for the date of service
of December 20, 2022, and another for the date of service of December 29, 2022. Though the Plan offers a
dental benefit in excess of Medicare coverage, the pontic is not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the retainer crown - porcelain/ceramic (D6740)
and pontic - porcelain/ceramic (D6245) provided on December 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies and non-sterile gloves.  
 
You asked the Plan to pre-approve incontinence supplies and non-sterile gloves. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies and non-
sterile gloves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for a wheeled walker provided to the enrollee on December 21, 2022.

You asked the Plan to pay for this item. You say that this claim should be paid. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted this claim denied because it was billed with an inappropriate modifier. The claim shows the provider billed this service with modifier NU which is used to report new equipment and KT which is applied to claims for off the shelf (OTS) items furnished to enrollees who reside in a competitive bidding area (CBA) and receive an OTS item from a supplier when they travel to another CBA or to an area outside the CBA.

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 could not be paid as billed due to an error with the modifiers used and from who the services were provided. A corrected claim is required. Therefore, we decided that the Plan does not have to pay for a wheeled walker provided to the enrollee on December 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shock reducing pylon and vacuum socket.

You asked the Plan to pre-approve a shock reducing pylon and vacuum socket. You say that you need this prosthetic in order to walk. The Plan denied your request. The Plan says that an upgraded pylon is not medically needed. The Plan also says a vacuum socket is experimental and cannot be approved.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a shock reducing pylon and vacuum socket. Our Medical Director states that the clinical documentation available in the case file does not support that a shock reducing pylon and a vacuum socket are medically reasonable and necessary for the enrollee in this case. Our Medical Director found that your condition does not meet criteria for coverage of a shock reducing pylon and vacuum socket.

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 shock reducing pylon and vacuum socket have not been met. Therefore, we decided that the Plan does not have to pre-approve a shock reducing pylon and vacuum socket.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network x-ray provided on June 19, 
2023. 
 
You asked the Plan to waive the copayment for an in-network x-ray. You say that you already paid a $30 
copayment. You should not have to pay anything else. 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 $150 
copayment for outpatient diagnostic tests and therapeutic services andsupplies. 
 
You have been asked to pay a $150 copayment for an in-network x-ray. This item/service falls within the 
outpatient diagnostic tests and therapeutic services andsupplies 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 $95.65. Therefore, we decided that the Plan does not have to waive the 
copayment for an in-network x-ray provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual and therapeutic massage therapy services provided 
on July 20, 2023. 
 
You asked the Plan to pay for manual and therapeutic massage therapy services. You say that you have been a 
member for a long time, and you would hope that your Health Plan would cover this. The Plan denied your 
request. The Plan says these requested services are excluded from Medicare coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for manual and therapeutic massage therapy services provided on July 20, 2023.