Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the manual wheelchair purchased May 16, 2023. 
 
You asked the Plan to reimburse you for the wheelchair. You say that Medicare could not rent you a 
wheelchair in a timely manner, so you purchased one from this supplier. The Plan denied your request. The 
Plan says the wheelchair was purchased from a supplier that does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the manual wheelchair 
purchased May 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an electronic connection between wheelchair
controller and one power seating system motor (E2310), harness (E2313), expandable controller (E2377),
integral knee pads (K0108 x2).

You asked the Plan to provide coverage for the requested power wheelchair accessories. You say that at the
time of the appeal, these accessories were medically necessary. The Plan denied your request. The Plan says
the Medicare coverage criteria were not met. Maximus partially overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct coverage criteria. The Plan noted these
connections were requested to control power tilt through the joystick. The notes state these are needed when 3
or more actuators are being used. The expandable controller (E2377) and harness (E2313) cannot be covered.
Only one power feature is requested (power tilt) on this wheelchair. In the presence of one power feature,
E2377 Expandable Controller and E2313 Expandable Controller Harness are never allowed. E2377 Expandable
Controller and E2313 Expandable Controller Harness cannot be covered. Although these items are requested,
no allowed amount is listed on the quote submitted as the vender concedes that the E2377 Expandable
Controller and E2313 Expandable Controller Harness are never allowed in this clinical situation.

The Plan is correct in this case. The Plan must follow Medicare has specific coverage criteria for the
accessories requested. Medicare also does not cover integral knee pads. Base on review of the medical records
provided and the notes from the vender, the requested accessories exceed the enrollees needs. Therefore, we
decided that the Plan does not have to provide coverage for an electronic connection between wheelchair
controller and one power seating system motor (E2310), harness (E2313), expandable controller (E2377),
integral knee pads (K0108 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on June 28, 2023. 
 
You asked the Plan to pay for the podiatry services. You say that you called the doctor's office and you were 
not informed the services performed would not be covered after you called to verify that it would. The Plan 
denied your request. The Plan says the cutting or removal of corns and calluses is a component of routine foot 
care. The documentation was reviewed and determined that Medicare criteria are not met as the medical record 
does not indicate that you have a significant systematic disease that necessitates foot care from a professional 
person. Additionally, routine foot care is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
podiatry services have not been met. Therefore, we decided that the Plan does not have to pay for podiatry 
services provided on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing home visit provided on June 7, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for a nursing home visit. You say that you are appealing the denial. The Plan denied 
your request. The Plan says their original decision to deny payment was correct. 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a nursing home visit provided on June 7, 2023, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83520 - 5 units and 87798-XU - 1 
unit) provided January 8, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 83520 immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of code 87798 
is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. 
 
We find that CPT code 83520 and 87798 is not supported in the medical record. Review of the medical records 
submitted do not include a signed physician order or signed laboratory requisition for the billed test. Based on 
this information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (83520 - 5 units and 
87798-XU - 1 unit) provided January 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endovenous ablation therapy and the phlebectomy to 
be provided by an OON provider.  
 
You asked the Plan to pre-approve the endovenous ablation therapy and the phlebectomy. You say that you are 
requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says this service 
is available with in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the endovenous ablation therapy and the phlebectomy to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary and mandibular denture (D5110 and 
D5120) provided on July 20, 2023. 
 
You asked the Plan to pay for D5110 and D5120. You say that this dental work was medically necessary. The 
Plan denied your request. The Plan says the denied dental service are not covered 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
complete maxillary and mandibular denture (D5110 and D5120) provided on July 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that you are requesting reconsideration of the denied
CGM. The Plan denied your request. The Plan says that Medicare criteria are not met. Maximus overturned the
Plan's denial because of a lack of information. The Plan requested a reopening and stated that the enrollee does
not meet criteria for a CGM. The Plan is correct in this case. The Plan has now provided medical records for
review. The documentation indicates that the enrollee does not use insulin with at least three daily injections.
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met.

Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor
(CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the service requested is not supported based on 
the records received.  
 
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. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Although you need 
physical and occupational therapy and could tolerate the therapy in the IRF, the complexity of your condition 
doesnt require an IRF stay and care can be provided in a lower level.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on July 
24, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. You say that you told receptionist at the 
dentist's office to check if services would be covered by your plan before performing them. You also say that 
you requested they would only carry services for covered items. The Plan denied your request. The Plan says 
your benefit for the requested the panoramic radiographic image 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 service was exhausted on date of service March 31, 2021 for an intraoral  
comprehensive series of radiographic images (D0210). Therefore, we decided that the Plan does not have to 
pay for the panoramic radiographic image (D0330) provided on July 24, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the SNF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for the SNF admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled 
therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on March 24, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the eye exam. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the eye exam provided on March 24, 2023, by an 
OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
in the home health or hospice setting, each 15 minutes (G0299) and services performed by a qualified physical 
therapist in the home health or hospice setting, each 15 minutes (G0151). You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration and 
submitted medical records to support appeal. The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented skilled nursing needs (i.e., intravenous' (IVs), complex wound care, new transfer 
factors (TFs), new ostomy). The enrollees heel wounds have healed. The enrollee lives wither her spouse in a 
facility with 24/7 assistance. The requested, ongoing, home health services are not medically necessary or 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve direct skilled nursing services of a registered nurse (RN) in the home health or 
hospice setting, each 15 minutes (G0299) and services performed by a qualified physical therapist in the home 
health or hospice setting, each 15 minutes (G0151).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the cardiac catheterization procedure and 
the laboratory services provided on June 9, 2023. 
 
You asked the Plan to reduce the coinsurance for the cardiac catheterization procedure and the lab services. 
You say that there were no local in-network providers. 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 10% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $271.55, which is 10% coinsurance for the allowed amount for the cardiac 
catheterization procedure ($2,715.45 allowed amount x 10% = $271.55). You have also been asked to pay 
$1.34, which is 10% coinsurance of the allowed amount for the lab services. ($13.39 allowed amount x 10% = 
$1.34). These items/services fall within the outpatient diagnostic tests and therapeutic services and supplies 
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 reduce the coinsurance for the cardiac catheterization 
procedure and the laboratory services provided on June 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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 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. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You can receive further services at 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site 
(D7953) provided on April 4, 2023. 
 
You asked the Plan to pay for the bone replacement graft for ridge preservation. You say that the bone 
replacement graft and the ensuing tooth implant are medically necessary to restore your tooth to its pre-
accident condition. You also say that will  allow you to bite and chew food as I did before the accident. The 
Plan denied your request. The Plan says this service is not a covered expense under your dental plan. 
 
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, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft for ridge preservation - per site (D7953) provided on April 4, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee cannot be safely discharged home. The 
Plan denied your request. The Plan says transfer to a SNF for inpatient skilled rehab services is not medically 
necessary for the enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 
The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.