Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to pay for inpatient care billed from January 17, 2021, to February 27,
2021.

You asked the Plan to pay this claim as billed. The Plan denied your request. The Plan says the itemized bill
shows the codes denied were billed incorrectly due to their inclusion in other services billed. Maximus
overturned the Plans denial as the itemized billed was not included in the case file. The Plan requested a reopen
and provided a copy of the itemized bill.

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, it has been confirmed those codes listed under "G" codes on the itemized
bill were denied as they are routine supplies or equipment or services whose cost is included in the procedure
charge and are not separately payable. Therefore, we decided that the Plan does not have to pay for inpatient
care billed to the enrollee from January 17, 2021, to February 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the exercise classes purchased on January 6, 2023.

You asked the Plan to pay for these services. You say that you do not receive a paid cash receipt for the classes.
The Plan denied your request. The Plan says the services do not qualify for reimbursement. Maximus
overturned the Plans denial. The Plan requested a reopen and provided additional information.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan reimburses up to
$150 per calendar year for qualified health club or fitness facility memberships and fitness classes and proof of
payment is required for reimbursement. The Plan's rules for coverage of gym benefits have not been met
because the Plan did not receive proof of payment in your reimbursement request. The original determination
stated that an Evidence of Coverage (EOC) was not received outlining the Plan's criteria for coverage;
however, one was received in a timely manner for the appeal request.

The reimbursement form that you filled out also states that proof of payment is required with the submission.
Therefore, we decided that the Plan does not have to pay for the exercise classes purchased on January 6, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service April 28, 
2023, to May 18, 2023. 
 
You asked the Plan to pay for procedure code 97010. You say that this service was necessary. The Plan denied 
your request. The Plan says procedure code 97010 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service April 28, 2023, to May 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 5, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 5, 2023, forward. You say that he 
services at issue were medically necessary. The Plan denied your request. The Plan says he 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 
November 5, 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 November 5, 2023, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond November 5, 
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 November 5, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 5, 
2023, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for procedure code 99491 billed to the enrollee for January 3, 2023.

You asked the Plan to pay for these services. 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 noted that this claim denied because
the diagnosis is inconsistent with the procedure. The Medicare billing guidelines show the Chronic Care
Management Services required elements are multiple (two or more) chronic conditions expected to last at least
12 months, or until the death of the patient, chronic conditions that place the enrollee at significant risk of
death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established,
implemented, revised, or monitored; first 30 minutes provided personally by a physician or other qualified
health care professional, per calendar month. The Plan states the appealed claim shows the provider has billed
this service with only primary diagnosis code I25.10 for Atherosclerotic heart disease of native coronary artery
without angina pectoris. This diagnosis code does not fit the documentation requirement for the billing of code
99491.

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 diagnosis code billed does not meet the criteria required for the code billed. Medicare rules for
payment of these services have not been met. Therefore, we decided that the Plan does not have to pay for
procedure code 99491 billed to the enrollee for January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313) and
electronic connection (E2311) for the enrollee.

You asked the Plan to pre-approve an expandable controller, harness and electronic connection. You say that
you are appealing the denial of the electronic controls required for this enrollee's power wheelchair. The Plan
denied your request. The Plan says that the upgraded electronics are not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable
controller, harness and electronic connection. Our Medical Director states that the available clinical
documentation in the case file does not support that the requested expandable controller, harness, and electronic
connection were 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 an 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 an expandable controller, harness and electronic connection have not been met.
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness
(E2313) and electronic connection (E2311) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization of iliac artery and tibial peroneal 
artery. 
 
You asked the Plan to pre-approve revascularization of iliac artery and tibial peroneal artery. You say that this 
is medically necessary. The Plan denied your request. The Plan says there is no documentation of 
hemodynamically significant stenosis in the iliac arteries bilaterally. 
 
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 revascularization of iliac artery and 
tibial peroneal artery. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no documentation suggesting limb 
threat. There is no narrative with respect to the description of enrollees symptoms. It is unclear if the enrollee 
is having lifestyle limiting claudication to suggest intervention would provide any meaningful benefit to his 
quality of life considering the risks. There is recent documentation that he denies claudication. No pulse 
examination is documented. No ankle brachia index is documented. Intervention of lower extremity arterial 
lesions in the absence of limb threat or lifestyle limiting symptoms is, in general, not advisable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization of iliac artery and tibial peroneal artery have not been met. 
Therefore, we decided that the Plan does not have to pre-approve revascularization of iliac artery and tibial 
peroneal artery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313) and
electronic connection (E2311) for the enrollee.

You asked the Plan to pre-approve an expandable controller, harness and electronic connection. You say that
the enrollee requires the requested wheelchair base and all of the recommended components to meet their
mobility, medical, and functional needs in their home. The Plan denied your request. The Plan says that
although there are three requested power options (tilt, recline and elevating leg rests), there is not a medical
need to control these power options through the joystick.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable
controller, harness and electronic connection. Our Medical Director states that the enrollee has a medical
history that includes stroke, heart disease, peripheral vascular disease, diabetes, hypertension, and chronic
kidney disease. The enrollee has right hemiplegia. His left upper extremity strength is documented to be five
out of five. The available clinical documentation in the case file does not support that the requested expandable
controller, harness, and electronic connection were 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 an
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 an expandable controller, harness and electronic connection have not been met.
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness
(E2313) and electronic connection (E2311) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing (96116, 96121, 96132, 
96133, 96138, 96139). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that this is medically necessary. The 
Plan denied your request. The Plan says there is insufficient evidence to conclude that repeat 
neuropsychological testing will influence your treatment. 
 
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 neuropsychological testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided records in this case do not document any objective measures 
of worsening cognition in the office visit notes. The records do not document how the repeat testing will be 
used in the treatment of your condition going forward.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing (96116, 96121, 96132, 96133, 96138, 96139).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided to the enrollee on September
9, 2022.

You asked the Plan to pay for the physician services. You say that you have provided proof of enrollment from
CMS for this provider. The Plan denied your request. The Plan says that this provider has been precluded from
participation in Medicare at the time services were rendered. Maximus overturned the Plan's decision for
insufficient information in the case file. The Plan requested a reopen and provided documentation to show that
as of April 20, 2022, the provider is in an exclusion status for Medicare claims.

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 except in cases involving emergencies or urgently needed care. There is no record of
a private contract between the provider and the enrollee to accept services by the rendering physician.
Therefore, we decided that the Plan does not have to pay for the physician services provided to the enrollee on
September 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (K0861) and related accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair and related accessories. You say that the 
requested items are a necessity for your care. The Plan denied your request. The Plan says rules for coverage 
for durable medical equipment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a Group 3 power wheelchair and related accessories are being requested for use in a SNF or 
hospital. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with 
multiple power options (K0861) and related accessories.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit (99284, 96372, 90715, 90471) 
provided on June 1, 2023. 
 
You asked the Plan to pay for the ER visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as the rendering provider 
is not enrolled 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 pay for an emergency room (ER) visit (99284, 
96372, 90715, 90471) provided on June 1, 2023.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided to the enrollee on May 1,
2022.

You asked the Plan to pay for the physician services. You say that you have provided proof of enrollment from
CMS for this provider. The Plan denied your request. The Plan says that this provider has been precluded from
participation in Medicare at the time services were rendered. Maximus overturned the Plan's decision for
insufficient information in the case file. The Plan requested a reopen and provided documentation to show that
as of April 20, 2022, the provider is in an exclusion status for Medicare claims.

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 except in cases involving emergencies or urgently needed care. There is no record of
a private contract between the provider and the enrollee to accept services by the rendering physician.
Therefore, we decided that the Plan does not have to pay for the physician services provided to the enrollee on
May 1, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services coded as 87150, 87801 (x2), and 87500 provided
to the enrollee on March 27, 2023.

You asked the Plan to pay for 87150, 87801 (x2), and 87500. You say that these codes should be paid. The
Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
billing criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. The medical records provided are insufficient to show the billing criteria for these
codes were met. Therefore, we decided that the Plan does not have to pay for lab services coded as 87150,
87801 (x2), and 87500 provided to the enrollee on March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for contact lenses provided on February 22, 2023. 
 
You asked the Plan to reimburse for contact lenses. You say that there is no question that contact lenses qualify 
and are eligible for reimbursement. You also say that in this case, you submitted the claim beyond the 120 days 
after the purchase. The Plan denied your request. The Plan says the claim submission deadline has been 
exceeded. 
 
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 these services when the reimbursement form and required documents are postmarked 
within 120 days of the purchase/service date. 
 
We looked at the file and the Plan's rules. The Plan rules say that you need to submit a reimbursement claim 
along with required documentation to the Plan. The Plan rules also say that this documentation must be 
postmarked within 120 days of the purchase/service date. The record shows that the reimbursement claim and 
required documentation were not received within the 120 days. Based on this information, we decided that the 
Plan's rules for coverage of contact lenses have not been met. Therefore, we decided that the Plan does not have 
to reimburse for contact lenses provided on February 22, 2023.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services provided to the enrollee
on June 12, 2022.

You asked the Plan to pay for the ER services. You say that the services were medically necessary. The Plan
denied your request. The Plan says that the provider is ineligible to be paid for services. Maximus overturned
the Plan's decision for insufficient information in the case file. The Plan requested a reopen and provided
documentation to show that as of April 20, 2022, the provider is in an exclusion status for Medicare claims.

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 except in cases involving emergencies or urgently needed care. There is no record of
a private contract between the provider and the enrollee to accept services by the rendering physician.
Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services provided to the
enrollee on June 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical placement of interim implant body (D6012) 
provided on July 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 surgical 
placement of interim implant body (D6012) provided on July 17, 2023.