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

 
We decided that the Plan does not have to pre-approve a contoured hand pad medium (K0108) and unilink hip 
guide receiver quantum (K0108 x3). 
 
You asked the Plan to pre-approve a contoured hand pad medium and unilink hip guide receiver quantum. You 
say that you would like the provided information to be looked at and for the wheelchair and accessories to be 
approved. The Plan denied your request. The Plan says the requested accessories do not primarily serve a 
medical purpose. 
 
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 a contoured hand pad medium and 
unilink hip guide receiver quantum. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a stroke and 
has a leg amputation. The enrollee has difficulty maintaining posture independently. Our reviewer found that 
the contoured hand pad is not medically necessary to support the enrollee's hand. Our physician reviewer also 
found that hip guides are not medically necessary to maintain posture for the enrollee and are not the standard 
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 a contoured hand pad medium and unilink hip guide receiver quantum have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a contoured hand pad medium 
(K0108) and unilink hip guide receiver quantum (K0108 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-cement or re-bond crown (D2920) provided on September 
12, 2023. 
 
You asked the Plan to pay for crown recement. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 re-cement 
or re-bond crown (D2920) provided on September 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve Methotrexate. You say that the enrollee needs for treatment. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methotrexate.   
Benefits for Methotrexate may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for advanced imaging provided on August 28, 
2023. 
 
You asked the Plan to waive the cost share for advanced imaging. 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 $500 deductible which applies to advanced imaging.  
 
The item or service you asked the Plan to waive the cost share for falls within the advanced imaging benefit 
category. You are being asked to pay is $210.88 towards your $500 deductible. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to advanced 
imaging. This cost sharing is a contractual obligation that had not been met at the time advanced imaging was 
received on August 28, 2023. Therefore, we decided that the Plan does not have to waive the cost share for 
advanced imaging provided on August 28, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF care provided from September 30, 2022, to October 
20, 2022. 
 
You asked the Plan to pay for the SNF care. You say that SNF care was medically necessary. The Plan denied 
your request. The Plan says daily skilled nursing services were not necessary. 
 
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 pay for 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 the enrollee did not require daily skilled nursing services, including complex wound 
management or administration of intravenous (IV) medications. The enrollee likely required continued 
assistance. However, this did not require the intensity of skilled therapy services provided in the skilled nursing 
facility setting. The skilled nursing facility care from September 30, 2022, to October 20, 2022, was not 
medically necessary. 
 
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 pay for the SNF care provided from September 30, 2022, to October 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system (A4305) and infusion 
supplies not used with a covered external infusion pump (A4223) provided June 18, 2023, to July 12, 2023. 
 
You asked the Plan to pay for the infusion supplies. You say that you provided IV infusion therapy for the 
enrollee at home and the home IV infusion supplies were omitted from the reimbursement. The Plan denied 
your request. The Plan says this service is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infusion supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for the disposable drug delivery system (A4305) and infusion supplies not used with a covered external 
infusion pump (A4223) provided June 18, 2023, to July 12, 2023.
Appeal type: Hospice
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 needs SNF assistance. The Plan denied 
your request. The Plan says the enrollee is under hospice election and that this type of request must be 
submitted to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. 
 The file shows the enrollee was under the Medicare hospice benefit at the time the SNF care was requested. 
The Plan is not able to pre-approve this service since they would not be responsible for paying for it. 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 pre-approve specialist care to be provided by an out-of-network 
provider. You asked the Plan to pre-approve specialist care. You say that there is not another specialist that is able to 
provide the care the enrollee needs. The Plan denied your request. The Plan says there are in-network providers 
available to provide the necessary care for the enrollee. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 specialist care. Our reviewer says that 
this service is not medically necessary with an out-of-network provider. Our physician reviewer found the 
record indicates that the enrollee was treated for an arteriovenous malformation in December 2022. The record 
provided does not establish that the enrollee is currently receiving any active treatment for their condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of specialist care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve specialist care to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiology services described by code 70450 performed on January 
12, 2023. 
 
You asked the Plan to pay for 70450. You say that 70450 should be paid as billed because it is a separately 
payable code and was billed with modifier -59. The Plan denied your request. The Plan says that 70450 is 
denied because it is bundled into payment for code 70496, and records do not support that 70450 was 
performed by the billing provider listed on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers/suppliers must report services 
correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes 
the services performed. 
 
We looked at the file and Medicare rules. In this case, we confirmed that 70450 is a column II code to column I 
code 70496, with a modifier indicator of 1. While 70496 and 70450 were both billed for the same date of 
service, they were performed by different providers. We confirmed that modifier -59 was correctly appended to 
70450 to indicate this was a separate and distinct service, as it was done by a different provider than 70496. 
The Plan also cites in their denial that the records indicate 70450 was performed by a provider other than the 
billing provider listed on the claim. We confirmed that modifier -Q6 was appended to code 70450. Modifier -
Q6 is used to indicate the billing of services for a locum tenens physician. As such, the use of the -Q6 modifier 
does explain why the report for 70450 is signed by a physician other than the billing physician on the claim, as 
this modifier indicates the billing physician is asking for payment for the services provided by the locum tenens 
physician. Based on this information, we decided that Medicare rules for coverage of 70450 have been met. 
Therefore, we decided that the Plan has to pay for the radiology services described by code 70450 performed 
on January 12, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's continued care. The Plan denied your request. The Plan says there would be no advantage in 
transferring the enrollee to a LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837) provided on April 14, 2021, to 
August 30, 2021. 
 
You asked the Plan to pay for the psychotherapy (90837). You say that the services should be covered. 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 the psychotherapy 
(90837) provided on April 14, 2021, to August 30, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visit (procedure 99285) provided on 
September 5, 2023. 
 
You asked the Plan to pay for emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue 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 CPT code. 
 
 In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for emergency department visit (procedure 99285). Our reviewer 
says that the service at issue in this case is not supported by the medical records. Our reviewer found the 
records support an appropriate history but does not support high level of medical decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of emergency department visit (procedure 99285) have not been met. Therefore, 
we decided that the Plan does not have to pay for emergency department visit (procedure 99285) provided on 
September 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on January 3, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of anesthesia during epidural steroid 
injections is not medically necessary. 
 
We looked at the file and Medicare rules. The services at issue are anesthesia given during an epidural steroid 
injection. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay 
for the anesthesia services rendered on January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a replacement Continuous Positive Airway
Pressure (CPAP) device.

You asked the Plan to provide coverage for a replacement CPAP device. You say that you lost your CPAP
machine on vacation and need it replaced. The Plan denied your request. The Plan says the lost machine was
issued in 2019 and would only be replaced if the equipment was damaged and could not be repaired. Neither
Medicare, nor the Plan replaces equipment for loss, theft, or neglect. Maximus overturned the Plans denial for
no medical records. 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 has specific coverage criteria
for the replacement of durable medical equipment. Medicare does replace lost or stolen equipment within five
years of issue. This equipment would not be available for replacement by the Plan until June 15, 2024.

Therefore, we decided that the Plan does not have to provide coverage for a replacement Continuous Positive
Airway Pressure (CPAP) device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye procedure provided on July 06, 
2023. 
 
You asked the Plan to waive the copayment for the eye procedure. You say that this procedure was done in the 
doctors office. 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 $250 
copayment for in-network outpatient surgery. 
 
You have been asked to pay a $250 copayment for the eye procedure. This item/service falls within the in-
network outpatient surgery 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. However, since the allowed amount is less than the standard copayment, you only owe 
$245.43. Therefore, we decided that the Plan does not have to waive the copayment for the eye procedure 
provided on July 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional payment for the porcelain/ceramic crown (D2740) 
provided on May 19, 2023. 
 
You asked the Plan to issue additional payment for this dental item. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says your benefit for 
the dental item provided 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 item provided has been exhausted. Specifically, the Plans contract states that the 
annual maximum dental benefit is $1,000. The Plan previously issued payments in the total amount of $1,000 
($347 + $187 + $277 + $188 + $1) for dental services provided in the 2023 calendar year. Therefore, you have 
exhausted the allowable benefit for the dental item provided in this case. Therefore, we decided that the Plan 
does not have to issue additional payment for the porcelain/ceramic crown (D2740) provided on May 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the upgraded electronics, toggle switches, tray
hardware, power mount bracket, cellphone holder and premium pad cover.

You asked the Plan to provide coverage for these power wheelchair accessories. The Plan denied your request.
The Plan says the required criteria for the upgraded electronics were not met and Medicare does not cover the
convenience accessories such as the cellphone hold and the premium pad cover. Maximus partially overturned
the Plans denial for the upgraded electronics. The Plan requested a reopen and stated that Maximus did not
apply the correct criteria. The Plan noted the medical records show the enrollee has adequate upper extremity
strength to operate the standard switches that come with approved power wheelchair.

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. The available clinical documentation in the case file
does not support that the requested upgraded electronics were medically reasonable and necessary for the
enrollee in this case. The notes do not show the medical necessity of controlling the power options through a
joystick.

As stated in the original decision, the cellphone holder and premium pad cover are convenience items and are
not covered by Medicare under any circumstance. Therefore, we decided that the Plan does not have to provide
coverage for the upgraded electronics, toggle switches, tray hardware, power mount bracket, cellphone holder
and premium pad cover.