Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for periodontal scaling and root planing
(D4342) and all 4 quadrants.

You asked the Plan to provide coverage for periodontal scaling and root planing (D4342) and all 4 quadrants.
The Plan denied your request. The Plan says these services are not a covered benefit under your contract.
Maximus overturned the Plans denial stating the contract submitted with the case file shows coverage for these
services. The Plan requested a reopen and noted that the incorrect contract was submitted with the original case
file and the correct contract was submitted for review.

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 requested are not among those covered under your 2023
dental this benefit.

Therefore, we decided that the Plan does not have to provide coverage for periodontal scaling and root planing
(D4342) and all 4 quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide continued coverage for an E0466 ventilator for the enrollee.

You asked the Plan to provide continued coverage for the requested ventilator. You say that at the time of the
appeal, this ventilator was medically necessary. The Plan denied your request. The Plan says Medicare
coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated
that Maximus did not apply the correct criteria. The Plan notes that as this ventilator was prescribed in a BiPAP
mode and there was no documentation that traditional BiPAP equipment had failed; the use of an E0466 device
exceeded the enrollee's need.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that when equipment coded
as E0466 is used to provide continuous positive airway pressure (CPAP) or BiPAP (with or without backup
rate) therapy, regardless of the underlying medical condition, this equipment will be denied as not reasonable
and necessary. The medical records show this ventilator was prescribed to be used in BiPaP mode. Medicare
rules for coverage have not been met. Therefore, we decided that the Plan does not have to provide continued
coverage for coverage an E0466 ventilator for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for codes 87631 and 87798.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and demonstrated that this claim denied
because this service was inappropriately billed. The records show 26 viruses were tested. The appropriate code
for this testing would be code 87633 defined as infectious agent detection by nucleic acid (DNA or RNA);
respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus,
respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and
multiplex amplified probe technique, multiple types or subtypes, 12-25 targets. Code 87798 is inclusive to code
87633, the panel code that should have been billed. The claim was coded incorrectly; therefore, Medicare
billing criteria were not met.

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, the claim should have been billed with code 87633 instead of code 87798 and/or 87631. Medicare
rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay
for procedure codes 87631 and 87798.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the
enrollee.

You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, SNF admission
was medically necessary 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 apply the correct criteria. The Plan noted that the enrollee was discharged to a SNF the day
after hip replacement, which is typically not the standard of care. The medical records do not show the enrollee
required daily skilled nursing and daily skilled therapy services at an inpatient level of care.

The Plan is correct in this case. 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.
Whether or not a SNF admission would be "beneficial" as previously stated is not of issue. Enrollees must meet
specific coverage criteria at the time of the appeal for SNF admission to be approved. Based on the medical
records provided, the Medicare rules for coverage of SNF care were not met at the time of the appeal. The
records do not show the enrollee required daily skilled nursing and/or daily skilled therapy services at an
inpatient left of care at a SNF facility. Therefore, we decided that the Plan does not have to provide coverage
for skilled nursing facility (SNF) care for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Evenity for the enrollee.

You asked the Plan to provide coverage for Evenity. You say that at the time of the appeal, this drug was
medically necessary. The Plan denied your request. The Plan says the Plans step therapy criteria were not met.
Maximus overturned the Plans denial for a lack of contract in formation submitted showing step therapy was
required. The Plan requested a reopen and provided the required step therapy information.

The Plan is correct in this case. 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. The Plan requires the enrollee to try and fail Prolia. The medical
records do not show the enrollee is unable to be treated with Prolia. Based on this information, we decided that
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to
provide coverage for Evenity for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a continuous glucose monitor (CGM).

You asked the Plan to provide coverage for a continuous glucose monitor (CGM). You say that at the time of
the appeal, this equipment was medically necessary. 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 apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a continuous
glucose monitor (CGM).

The Maximus Physician Reviewer determined that the enrollee was having low blood glucose levels despite
not being on insulin. "Glipizide can also cause dangerous low blood glucose levels and even though your levels
are listed at 55 and above, this is very close to the 54-level listed in the coverage criteria." The reviewer
determined that it would be medically necessary to approve a CGM to help warn of low blood glucose
levels and help prevent them.

The Plan requested a reopen and stated that the regulations clearly state enrollees must have a blood sugar level
less than 54 mg/dL. It did not indicate that the criteria can be met if the documented glucose level is "close to"
54mg/dL. The plan states that it should also be noted that the treatment for diabetes did not change despite the
glucose level of 55mg/dl.

The medical records show you have a diagnosis of type 2 diabetes with
hyperglycemia, treated with 3 oral hypoglycemic drugs. It is documented that the enrollee
was experiencing episodes of hypoglycemia, with blood sugar levels between 54 and 69 mg/dL. The enrollee
was deemed to be a candidate for a CGM because of hypoglycemia unawareness. The Plan is correct in this
case. LCD L33822 states that a beneficiary must meet all of the coverage criteria to be eligible for coverage of
a CGM and related supplies. In this case, the documentation does not support that you are insulin-treated, or
have a history of problematic hypoglycemia with documentation of at least one of the following: Recurrent
(more than one) level 2 hypoglycemic events (glucose <54mg/dL (3.0mmol/L)) that persist despite multiple
(more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan; or a history of one
level 3 hypoglycemic event (glucose <54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical
state requiring third-party assistance for treatment of hypoglycemia, as required by the LCD. Medicare
coverage criteria are not met.

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 continuous glucose monitor (CGM) have not been met. Therefore, we decided
that the Plan does not have to provide coverage for a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Afirma Genomic Sequencing Classifier Oncology
(Thyroid) Testing for the enrollee.

You asked the Plan to pre-approve this testing. You say that at the time of the appeal, this testing was
medically necessary. 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 apply
the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Afirma Genomic
Sequencing Classifier Oncology (Thyroid) Testing. The Maximus Physician Reviewer determined that the
requested service was medically reasonable and necessary for the enrollee in this case. The reviewer found that
the enrollee has a follicular thyroid lesion with atypia of unknown significance. The Plan requested a reopen
stating Maximus did not apply the correct criteria. The medical records show the enrollee has a thyroid nodule. It is documented in the Endocrine Metabolic Associates note, that the enrollee had no complaints of weight change, bowel habit change, heat/cold intolerance, tremors, or palpitations/anxiety. She denied any change in the size of shape of the neck, or difficulty swallowing. There was no history of exposure to fallout radiation or radiation therapy.

There was no family history of thyroid disease. An ultrasound-guided needle aspiration, demonstrated atypia of undetermined significance. The Plan is correct in this case. The documentation does not support that the coverage criteria as established by LCA A54356 were met for this enrollee, as she did not have
a documented history or characteristics suggesting malignancy such as: nodule growth over time, a family
history of thyroid cancer, hoarseness, difficulty swallowing or breathing, a history of exposure to ionizing
radiation, a hard nodule compared with rest of gland consistency, or the presence of cervical adenopathy.
Medicare coverage criteria are not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not
have to pre-approve Afirma Genomic Sequencing Classifier Oncology (Thyroid) Testing for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee.

You asked the Plan to pay for inpatient services provided. You
say that these services were provided to the enrollee and should be covered by the Plan. The Plan denied your
request. The Plan says, the enrollee was no longer receiving active treatment and was
waiting for placement to a lower level of care. The Plan says that the provider was notified of non-coverage but
chose to continue to treat the enrollee at an inpatient level of care. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. Review of the medical records for the dates in
question show the enrollee was stable and waiting for SARS placement, however the hospital was working
with providers trying to find both an available bed and a facility within the Plans network. Continued inpatient
care for placement or social reasons is not covered by Medicare.

Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for oxygen equipment from July 13, 2021, to October
13, 2021, and for August 13, 2022.

You asked the Plan to reimburse you for this equipment. The Plan denied your request. The Plan says the
request for the dates in 2021 were untimely and there is no proof of payment for the date in 2022. Maximus
partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
contract requirement information. Your contract with the Plan clearly says that you must request payment for
claims within 12 months and must provide proof of payment. The dates of service in 2021 were not appealed
within the required timeframe. You did not provide a receipt to show proof of payment for the August 2022
request. These are contractual requirements enrollees must follow for reimbursement. Therefore, we decided
that the Plan does not have to reimburse you for oxygen equipment from July 13, 2021, to October 13, 2021,
and for August 13, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a porcelain/ceramic crown for tooth #30.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says that the criteria for coverage are not met.

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. The Plan covers these services
when the services are medically necessary and reasonable.

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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the submitted records and x-rays indicate
that the enrollee has a failing amalgam restoration on tooth #30 that exhibits recurrent caries, with visible
cracks in the medial and distal marginal ridges of the tooth. A crown restoration is medically reasonable and
necessary to prevent fracture and provide good masticatory function. The criteria for coverage are met and the
crown for tooth #30 is medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of these services have been met. Therefore, we decided that the Plan has to preapprove
a porcelain/ceramic crown for tooth #30.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair (E0240), crutch substitute, ankle compression sleeve, ankle brace and positioning pillow purchased from Amazon.com.

You asked the Plan to pay for these items. You say that these items were medically necessary. The Plan denied your request. The Plan says these items are not covered by Medicare. Maximus upheld the Plans decision. You requested an ALJ hearing. It was discovered during the hearing that Maximus did not render a decision on all of the items under appeal. Maximus reopened the case and has now addressed all items ordered.

The Plan must follow Medicare rules. Medicare does not provide coverage for precautionary equipment, such as a shower chair (E0240), crutch substitute (E0118), ankle compression sleeve, ankle brace and positioning pillow (E0190). Medicare also does not pay for durable medical equipment purchased from online commercial retailers as they do not participate in the Medicare billing structure for providers. While these items may have been beneficial for your use, they are not covered by the Plan nor by Medicare and they were purchased from an ineligible durable medical equipment provider. Therefore, we decided that the Plan does not have to pay for a shower chair (E0240), crutch substitute, ankle compression sleeve, ankle brace and positioning pillow purchased.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service May 18, 
2023. 
 
You asked the Plan to pay for procedure code 99232. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the service at issue was not billed with the required 
modifier to allow separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 69601 
provided on May 19, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99232 billed for 
date of service May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing home visits provided from March 4, 2023, to March 
30, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for nursing home visits. You say that it is the nursing home's responsibility to obtain 
authorization. The Plan denied your request. The Plan says that the 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 nursing home visits provided from March 4, 2023, 
to March 30, 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 urine polymerase chain reaction (PCR) panel testing 
provided on May 17, 2023, and billed with codes 87481, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing should be billed with a 
single panel code. The Plan denied your request. The Plan says this testing was medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel testing have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel testing provided on May 17, 2023, and billed with codes 87481, 87653, 87798, and 87801.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on March 15, 
2023. 
 
You asked the Plan to pay for dental services. You say that you believe these services should be covered. The 
Plan denied your request. The Plan says this provider has opted out of Medicare. 
 
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 except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided by an opt-out provider on March 15, 2023.