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

 
We decided that the Plan does not have to pay for the self-administered drugs (non-covered services A2970) 
provided on May 22, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that all treatments provided were medically 
necessary to save your life. The Plan denied your request. The Plan says that self-administered drugs are not 
covered as a medical benefit under the Plan. 
 
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. Therefore, we decided that the Plan does not have to pay for the self-administered drugs (non-
covered services A2970) provided on May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for photochromatic tint (V2744), frames (V2020) and 
progressive lenses (V2781) provided on June 9, 2023. 
 
You asked the Plan to pay for photochromatic tint (V2744), frames (V2020) and progressive lenses (V2781). 
You say that this provider is in the network. The Plan denied your request. The Plan says this benefit has been 
exhausted with this benefit.  
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $200 benefit toward the purchase and fitting of eyeglasses and pair of lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $200 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses. The Plan rules also say you pay any amount over the $200 retail 
price. The record shows that according to the claim submission, the submitted charge was $375. After 
deducting the $200 benefit allowance, $175 remained. Then you received a 20% discount on items not covered 
by the Plan at in-network locations, leaving a member responsibility as $140 ($375 - 200 = $175, $175 - 20% = 
$140). Based on this information, we decided that the Plan's rules for coverage of photochromatic tint (V2744), 
frames (V2020) and progressive lenses (V2781) have not been met. Therefore, we decided that the Plan does 
not have to pay for photochromatic tint (V2744), frames (V2020) and progressive lenses (V2781) provided on 
June 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes J2916 and Q4081 related to end-stage renal 
disease (ESRD) provided on April 1, 2023, to April 29, 2023. 
 
You asked the Plan to pay for procedure codes J2916 and Q4081. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related services. 
 
The Plan must follow Medicare rules. Medicare rules state that all ESRD-related injectable drugs and 
biologicals and oral equivalents of those injectable drugs and biologicals are included in the ESRD PPS. No 
other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
procedure codes J2916 and Q4081 related to end-stage renal disease (ESRD) provided on April 1, 2023, to 
April 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Infuse BMP-2 allograft (20930). 
 
You asked the Plan to pre-approve the Infuse BMP-2 allograft. You say that this is medically necessary. The 
Plan denied your request. The Plan says the clinical value and effectiveness of the Infuse BMP-2 allograft in 
the setting of posterior lumbar spine fusion surgery 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 pre-approve the Infuse BMP-2 allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the BMP allograft is not approved for use in the posterior spine. It is 
experimental. 
 
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 Infuse BMP-2 allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Infuse BMP-2 allograft (20930).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for dates of service December 31, 2022, to 
January 29, 2023. 
 
You asked the Plan to pay for the billed services. You say that you placed the enrollee on hold while in the 
hospital. The Plan denied your request. The Plan says that the enrollee was an inpatient at the same time. 
 
The Plan must follow Medicare rules. Medicare rules say that beneficiaries do not have to be discharged within 
the period because of admissions to other types of health care providers. 
 
We looked at the file and the rules. The enrollee's claim information shows that the enrollee was discharged 
from inpatient care on January 22, 2023. The home health services during the period of care at issue were 
provided on January 23, 24, and 27, 2023, which is after the inpatient discharge date. The file does not show 
that home health care services were billed or provided while the enrollee was an inpatient. Based on this 
information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, we 
decided that the Plan has to pay for the home health care billed for dates of service December 31, 2022, to 
January 29, 2023.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid repair (V5014) provided on January 13, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, hearing aid repairs are not covered under the 
supplemental hearing aid policy. Therefore, we decided that the Plan does not have to pay for the hearing aid 
repair (V5014) provided on January 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown-porcelain fused to high noble metal for 
tooth number 31 (D6750).   
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item 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 Plan's 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 was previously exhausted. Specifically, the Plan's contract states that 
up to four units of fixed dentures are covered per year. The Plan previously issued approval for fixed dentures 
for teeth number 27, 28, 29, and 30. Therefore, you have exhausted the allowable benefit for the dental item 
requested in this case at this time. Therefore, we decided that the Plan does not have to pre-approve a retainer 
crown-porcelain fused to high noble metal for tooth number 31 (D6750).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 17, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from October 17, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from October 
17, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of October 17, 2023, forward. Our physician 
reviewer found the enrollee did not require inpatient mental health treatment beyond October 17, 2023, as she 
was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not 
appear that active treatment was taking place beyond the date in question. It did not appear that the services for 
the dates in question were reasonably expected or medically necessary to improve the enrollees condition or 
for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from October 17, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 17, 
2023, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings (A6530 x 2). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings (A6530 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on March 18, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you have been trying to get reimbursed for years. 
You say you do not know why your husband's appeal was overturned and not yours. You say you got the 
hearing aids from the same provider. The Plan denied your request. The Plan says the provider was out-of-
network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only received by a network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the provider was out-of-network. Therefore, we 
decided that the Plan does not have to pay for the hearing aids provided on March 18, 2021.
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 stating IRF care would be beneficial. The Plan requested a reopen and
noted that Maximus did not apply the correct criteria. The Plan noted the medical records show at the time of
the appeal the enrollee's ability to participate in intensive therapy was described as limited by the hospital
physical therapist, given their dizziness, pain and poor activity tolerance.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that IRF admission is
covered only when it is medically reasonable and necessary as described in the Medicare rules section.
Enrollees must have the ability to participate in at least three hours of therapy per day at least five days per
week. Whether or not the admission may eventually be beneficial for the enrollee is not of issue. The enrollee
must meet the criteria for approval at the time of the request. Based on the medical records, the 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for special supplemental benefits for the
chronically ill (SSBCI).

You asked the Plan to provide coverage for these type of benefits. You say that the Plan denied your request.
The Plan says at the time of the appeal, you did not meet the criteria required for these benefits. Maximus
overturned the Plans denial for a lack of medical documentation in the case file. The Plan requested a reopen
and provided additional information from your physician showing you do not meet those criteria.

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. Your contract with the Plan clearly states specific documentation must be provided
by your physician to show you meet the criteria required for this benefit.

Based on the documentation submitted by your physician, the required criteria are not met. Therefore, we
decided that the Plan does not have to provide coverage for special supplemental benefits for the chronically ill
(SSBCI).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to reimburse the partial adjustment for dates of service November 05,
2021, to December 04, 2021, for service provided to the enrollee.

You asked the Plan to review and reimburse a partial adjustment. You say that you do not believe the partial
adjustment made by the Plan was correct. The Plan denied your request. The Plan says this case is a payment
integrity post-service, post-payment review of a claim for reimbursement. There is no dispute that the member
received home health care services. The issue is the claim was paid at a higher rate than the documentation
supported. The billed HIPPS code submitted, and payment received represented institutional admission source
as inpatient. However, the facility claim for the treatment prior shows the enrollee was treated on an outpatient
basis and not in an inpatient admission. Therefore, this changes the rate of payment on the claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, the claim for home health services shows the prior source to be inpatient admission. The Plan has
provided the claim for the prior service which shows outpatient treatment. Therefore, we decided that the Plan
does not have to reimburse the partial adjustment for dates of service November 05, 2021, to December 04,
2021 provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a Personal Emergency Response System (PERS).

You asked the Plan to provide coverage for this equipment. The Plan denied your request. The Plan says items
covered by the OTC benefit cannot be pre-approved. They must be purchased by you with the OTC benefit
card as those funds are distributed separately. Maximus overturned the Plans denial. The Plan requested a
reopen and noted that Maximus did not apply the correct contract language.

The Plan is correct in this case. Medicare does not cover personal alert systems as they are precautionary
equipment. The Plan provides coverage for this type of equipment or allows coverage, with the use of the $475
benefit attached to the OTC benefit card.

To obtain the items listed as available for purchase by this OTC benefit, enrollees must follow the Plan contract
rules and have the equipment provider apply the cost of the item to the OTC card. These items cannot be preapproved
by the Plan because the provider will not be paid with Medicare funds. The provider will be paid with
supplemental benefit funds included in the $475 applied to that card. If at the time of the request, your benefit
card does not have the funds available for payment and/or of the provider will not accept your OTC benefit
card, the Plan is not required to pre-approve coverage.

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 clearly states the OTC benefit care is a limited
supplemental benefit with limitations. Pre-approval of this type of equipment is not covered. Therefore, we
decided that the Plan does not have to provide coverage for a Personal Emergency Response System (PERS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS) unit
supplies billed to the enrollee for October 3, 2022.

You asked the Plan to pay for this claim. You say that these supplies should be paid by the Plan. 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 the provider has been submitting claims for A4595
Electrical stimulator supplies, 2 lead, per month since December 4, 2020. Per LCD L33802 for all items that
are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver
designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request
from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable
and necessary. Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected
utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients.
Suppliers must verify with the treating practitioners that any changed or atypical utilization is
warranted. Regardless of utilization, a supplier must not dispense more than a three (3) - month quantity
at a time. The provider did not submit any evidence that they have been contacting the member before shipping
additional supplies. A 4-lead TENS unit may be used with either 2 leads or 4 leads, depending on the
characteristics of the enrollee's pain. If it is ordered for use with 4 leads, the medical record must document
why 2 leads are insufficient to meet the beneficiary's needs. Supplies Separate allowance will be made for
replacement supplies when they are reasonable and necessary and are used with a covered TENS. Usual
maximum utilization is: 2 TENS leads - a maximum of one unit of A4595 per month, 4 TENS leads - a
maximum of two units of A4595 per month. The only records received from the member's treating doctor is
dated 03/05/20. There are no updated visits documented stating the member's continued need for these
supplies. There is no information from our member indicating she has requested these supplies. The enrollee's
plan has changed since 2020. Review of all claim's history does not locate a TENS unit was ever supplied to
the member in March of 2020. Therefore, the required billing criteria are not met.

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 a lack of documentation to
show the required billing guidelines were met. Therefore, we decided that the Plan does not have to pay for
Transcutaneous Electrical Nerve Stimulators (TENS) unit supplies billed to the enrollee for October 3, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on October 21, 2022.

You asked the Plan to pay for this claim. You say that this testing should be covered by the Plan. 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 the DEX Diagnostic Exchange Registry shows DEX Z-Code
ZBBLD has a coverage status of "Not Covered". Based on this guideline, the Plan has correctly denied the
claim for payment the reported Z-Code ZBBLD is not covered for the MoIDX program for Medicare claims.

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 Z-Code
reported. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does
not have to pay for genetic testing provided to the enrollee on October 21, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on September 28, 2022.

You asked the Plan to pay for this claim. 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 the
DEX Diagnostic Exchange Registry show DEX Z-Code ZBBIA has a coverage status of "Not Covered".
Per this Medicare guideline, the Plan has correctly denied the claim for payment as Z-Code ZBBIA is not
covered 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, this claim was submitted with a non-covered Z-Code. Medicare rules for
coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for genetic
testing provided to the enrollee on September 28, 2022.