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

 
We decided that the Plan does not have to waive the copayments for each emergency room visit provided from 
September 29, 2022, to September 30, 2022. 
 
You asked the Plan to waive the copayments for each emergency room visit. You say that you had to go back 
the next day because the surgical glue was not holding. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for each emergency room visit.  
 
You have been asked to pay a $120 copayment for each emergency room visit. This item/service falls within 
the emergency care benefit category. You have been asked to pay a total of $240 ($120 copayment per visit x 2 
visits = $240). This means that you have been asked to pay the correct amount based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayments for each emergency room visit provided from 
September 29, 2022, to September 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the minimally invasive lumbar decompression (MILD) procedure provided to the enrollee on October 19, 2022.
You asked the Plan to pay for the MILD procedure. You say that medical records were provided. The Plan denied your request. The Plan says that a clinical trial number is missing. Maximus overturned the Plan's denial. The Plan requested a reopening and states that this service cannot be covered unless provided in a clinical trial. The Plan is correct in this case.
The claim submitted to the Plan did not include a clinical trial number and no other information was provided to indicate the enrollee was part of a clinical trial. Therefore, we decided that the Plan does not have to pay for the minimally invasive lumbar decompression (MILD) procedure provided to the enrollee on October 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Prolia. Our Medical Director states that the use of Prolia in this setting is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal and would not be considered safe and effective and otherwise 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 Prolia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgery services provided for procedure codes 15002, 15004, 20700, and 97606 on March 31, 2022.
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 Medicare billing criteria were not met. Maximus partially overturned the Plans denial based on medical necessity. The Plan requested a reopen and noted this was not a medical necessity issue. This was a billing discrepancy due to an inappropriate modifier on the claim.
The Plan noted that providers are only required to include the AS modifier with the 82 modifiers if services are rendered in a Method II CAH as stated in Medicare Claims processing Manuel Chapter 4 Section 250.9. As these services were not considered a Critical Access Hospital Outpatient Billing event, the provider needed to follow the Medicare coding guidelines as provided under Medicare claims processing manual Chapter 12, Section 20.4.3 and the Assistant at surgery modifier fact sheet which states procedures billed with the assistant-at-surgery (physician modifiers -80, -81, -82, or the AS modifier for physician assistants, nurse practitioners and clinical nurse specialists, are subject to the assistant-at-surgery policy. Accordingly, Plans should pay claims for procedures with these modifiers only if the services of an assistant-at-surgery are authorized. The "82" modifier is used when the assistant at surgery service was provided by a medical doctor there was not a qualified resident available. Documentation must include information relating to the unavailability of a qualified resident in this situation. The AS modifier is used for assistant at surgery services provided by a physician's assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). The provider must accept assignment. The claim submitted does not meet these filing criteria. Therefore, based on these guidelines, the Plan has correctly denied the claim for payment.
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 codes and when necessary, the appropriate modifiers. In this case, this claim was not submitted correctly based on the billing guidelines. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for assistant surgery services provided for procedure codes 15002, 15004, 20700, and 97606 on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 1, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the enrollee was seen for problems with diabetes. 
The Plan denied your request. The Plan says the billed codes are not supported. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. 
 
Providers must report services with the appropriate CPT code. The CPT Code Manual definition of code 96521 
is refilling and maintenance of portable pump. The records provided do not show this service was rendered. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cala Trio therapy system (K0108). 
 
You asked the Plan to pre-approve the Cala Trio therapy system. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this item is considered experimental. 
 
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 Cala Trio therapy system. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this item is considered 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 Cala Trio therapy system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Cala Trio therapy system (K0108).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unattended sleep study (95806). 
 
You asked the Plan to pre-approve an unattended sleep study. The Plan denied your request. The Plan says this 
request is not medically necessary because the enrollee does not have signs or symptoms of any of the 
conditions listed by Medicare for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that repeat polysomnography/sleep testing may be 
indicated for the criteria listed in the Medicare rules section of this letter. 
 
 
 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 an unattended sleep study. Our 
reviewer says that no sleep study is indicated per the documentation provided. Our physician reviewer found 
the documentation is unclear as to why this patient requires a repeat study since there is documented 
obstructive sleep apnea (OSA). There are no signs, symptoms or complaints related to OSA. Our reviewer 
found that the chart lists the OSA in the history but does not elaborate if the patient is currently being treated 
for or severity of the disease. Our physician reviewer also found that the documentation is lacking to clearly 
understand what is being asked by the physician. 
 
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 unattended sleep study have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an unattended sleep study (95806).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient diagnostic tests provided on April 
24, 2023. 
 
You asked the Plan to waive the cost share for outpatient diagnostic tests. You say that you disagree with the 
cost share. 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. Your 
contract with the Plan says that there is a $850 deductible which applies to outpatient diagnostic tests/basic 
radiological services.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient diagnostic 
tests/basic radiological services benefit category. You are being asked to pay $724.47 towards your $850 
deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $850 
deductible which applies to outpatient diagnostic tests/basic radiological services. This cost sharing is a 
contractual obligation that had not been met at the time outpatient diagnostic tests was received on April 24, 2023. Therefore, we decided that the Plan does not have to waive the cost share for outpatient diagnostic tests 
provided on April 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2750) provided on May 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had to have the crown removed because 
you had developed a cavity under the crown. The Plan denied your request. The Plan says your annual dental 
allowance amount has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 5, 2023. It is the 
enrollees responsibility for any amount over the $1,000 annual dental allowance amount. Therefore, we 
decided that the Plan does not have to pay for a crown (D2750) provided on May 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this does not meet the criteria for coverage. 
 
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 facet joint injections. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found there are other pain generators shown 
on the imaging. Therefore, the request does not meet the LCD criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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. 
 
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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of osteoarthritis of right knee. The documentation does not support that the 
enrollee has tried and failed Monovisc, Orthovisc, Synvisc, or Synvisc One. The documentation does not 
support that Monovisc, Orthovisc, Synvisc, or Synvisc One would likely be less effective and/or likely have 
adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interrogation device evaluation(s) provided on May 10, 
2023. 
 
You asked the Plan to pay for interrogation device evaluation(s). You say that this service is supported in the 
records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for interrogation device 
evaluation(s) provided on May 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (E1230). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that your scooter was stolen, and you 
were advised a new one could be obtained. You also say that the person who came out to evaluate you noticed 
an old walker, but that walker is no longer available to you, and you depend solely on the scooter. The Plan 
denied your request. The Plan says the power scooter requested does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 a power operated vehicle. Our reviewer 
says that you do not meet the criteria for coverage. Our physician reviewer found per the physical therapy 
evaluation, you are able to use a walker in the home but want the device to have greater access to your 
apartment community. Our reviewer also found that you do not require a power operated vehicle to manage 
self-care in the home. 
 
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 power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power operated vehicle (E1230).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty power scooter, weight capacity 451 to 600 
pounds. 
 
You asked the Plan to pre-approve a heavy-duty power scooter. You say that you cannot walk. You say that 
you can barely get around your home. You also say that you are unstable, and legs hurt to walk. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a power operated vehicle (POV) may be covered 
when the beneficiarys weight is less than or equal to the weight capacity of the POV that is provided and 
greater than or equal to 95% of the weight capacity of the next lower weight class POV. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy-duty power scooter have not been met. Specifically, the provided records do not support 
that you meet the weight requirements for the requested power scooter. Therefore, we decided that the Plan 
does not have to pre-approve a heavy-duty power scooter, weight capacity 451 to 600 pounds.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 26, 
2023, to July 5, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $350 copayment per day for days 1-5 for inpatient hospital care. The total 
amount you owe is $1,750 ($350 x 5 days = $1,750). This item/service falls within the inpatient hospital care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided 
on June 26, 2023, to July 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on December 27, 2022.
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 substantiated by the limited records provided. Maximus overturned the Plans denial. The Plan requested a reopen and stated this was an out of network service without prior authorization. The Plan stated a denial was made based on the limited records submitted with the claim.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of these services were met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on December 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility visit provided on June 22, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the nursing facility visit. You say that the services were medically necessary. 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 the nursing facility visit provided on June 22, 
2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 33361 billed for date of service March 14, 2023. 
 
You asked the Plan to pay for the billed services. You say that the records support the services provided. The 
Plan denied your request. The Plan says that a clinical trial number was not billed. 
 
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 33361 is transcatheter aortic valve replacement 
(TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach. We find that the services at issue 
were correctly coded, including a valid clinical trial number in field 19 as required. 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 procedure code 33361 billed for date of service March 14, 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.