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

 
We decided that the Plan does not have to pay for a re-cement or re-bond crown (D2920) provided on October 
11, 2022. 
 
You asked the Plan to pay for the re-cement or re-bond crown. You say that at the time of service it was 
absolutely necessary because the crown was very loose. You are requesting payment because you are on a 
fixed income and have many medical expenses. The Plan denied your request. The Plan says this service is not 
covered under the benefit package.  
 
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 re-
cement or re-bond crown (D2920) provided on October 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, the lenses, and the anti-reflective coating 
provided on September 29, 2022.  
You asked the Plan to pay for the frames, the lenses, and the anti-reflective coating. You say that you were told 
the eyeglasses would not go over $200. You say the provider charged $375 and you were billed $175. The Plan 
denied your request. The Plan says the benefit maximum has been reached. 
 
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 up to a $200 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid the $200 allowance towards the vision 
items which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of 
the frames, the lenses, and the anti-reflective coating have not been met. Therefore, we decided that the Plan 
does not have to pay for the frames, the lenses, and the anti-reflective coating provided on September 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete denture - maxillary (D5110) and complete denture 
- mandibular (D5120) provided on December 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $2,000 annual maximum 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. Therefore, we decided that the Plan does not have to pay for complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided 
on December 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September 
29, 2022, through October 28, 2022. 
 You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the enrollee did not require skilled services for the requested time.  
 
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 have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from September 29, 2022, through October 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for  durable medical equipment (DME) 
provided on January 16, 2023. 
 
You asked the Plan to waive the cost share for  DME. 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 $800 deductible and a 10% coinsurance, which applies to durable 
medical equipment (DME).  
 
The item or service you asked the Plan to waive the cost share for falls within the durable medical equipment 
(DME) benefit category. You are being asked to pay $458.04 towards your $800 deductible. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $800 deductible and a 10% 
coinsurance, which applies to durable medical equipment (DME). This cost sharing is a contractual obligation that had not been met at the time DME was received on January 16, 2023. Therefore, we decided that the Plan 
does not have to waive the cost share for  durable medical equipment (DME) provided on January 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you should qualify because you have a large 
residual tumor that remains in the brain and oppresses your nervous system. The Plan denied your request. The 
Plan says the criteria for eligibility have not been met.  
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CTA of the chest provided on January 6, 2023. 
 You asked the Plan to pay for a CTA of the chest. You say that the enrollee was no longer active in hospice at 
the time of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 5, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for a CTA of the chest 
provided on January 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on April 18, 2022, billed with two units of code 77002. 

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 partially overturned the denial for one unit. The Plan requested a reopen and noted that per Medicare NCCI Medically Unlikely Edits (MUEs) Practitioner Services effective April 1, 2022, procedure code 77002 has a MAI of 3 and a MUE value of 1 per date of service. Per the 2022 National Physician Fee Schedule, procedure code 77002 has a bilateral indicator of 0. Per NCCI chapter 1, Section V, part 3A i indicates, if the bilateral surgery indicator is "0," a bilateral
procedure must be reported with "1" unit of service. There is no additional payment for the code if
reported as a unilateral or bilateral procedure because of anatomy or physiology. Alternatively, the code
descriptor may specifically state that the procedure is a unilateral procedure, and there is a separate code
for a bilateral procedure. As code 77002 has a bilateral indicator of 0, it must be reported with one unit and no additional payment made if reported as bilateral unless a separate code for bilateral procedure is billed.
Per these billing guidelines, the Plan has correctly denied the claim for payment as the provider
did not bill the code correctly. 

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, this claim could not be paid as billed due to the indicator assigned to code 77002. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on April 18, 2022, billed with two units of code 77002.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that you would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an MRI of the 
lumbar spine is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI of the lumbar spine. Our 
reviewer says that an MRI of the lumbar spine is not medically necessary. Our physician reviewer found that 
you have chronic low back pain and right sciatica. The records do indicate that you have been evaluated for 
your condition previously as well as having physical therapy and sacroiliac joint injections without relief, 
however there is no detail on when the therapies were applied. Also, there are no red flags to mandate an 
immediate MRI without a trial of conservative management. Therefore, without the knowledge of when and 
how long the physical therapy was administered and the time of the sacroiliac joint injections the medically 
necessity of the MRI of the lumbar spine cannot be established.  
 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 MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Mohs micrographic technique (procedure codes 17311,
17312) provided to the enrollee on December 16, 2021.
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. The
Plan requested a reopen and provided additional information. The Plan noted that review of the claim history
shows the enrollee received pathology services of 88305 by another physician on the same date of service.
Mohs micrographic surgery (codes 17311-17315) is performed to remove complex or ill-defined cutaneous
malignancy. A single physician performs both the surgery and pathologic examination of the specimen(s). The
Mohs micrographic surgery codes include skin biopsy and excision services (codes 11102-11107, 11600-
11646, and 17260-17286) and pathology services (88300-88309, 88329-88332). Reporting these latter codes in
addition to the Mohs micrographic surgery codes is inappropriate. Pathology services of 88305 being billed on
the same date as Mohs micrographic surgery (codes 17311-17315) would be considered inappropriate unless it
was billed with a modifier -59 which in this case it was not. The Plan notes the provider submitted a
corrected claim on November 04, 2022, adding the appropriate -59 modifier which processed and paid
on November 25, 2022. Therefore, the Plan asserts the original claim denied correctly.
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 original claim submitted could not be
paid as billed and the Plan indicates a corrected claim was received and paid. Therefore, we decided that the
Plan does not have to pay for Mohs micrographic technique (procedure codes 17311, 17312) provided to the
enrollee on December 16, 2021, as originally billed.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor-controlled foot (L5973). 
 
You asked the Plan to pre-approve a microprocessor-controlled foot. You say that the enrollee needs this type 
of prosthetic. The Plan denied your request. The Plan says that the request of new prostheses exceeds the 
enrollee's functional need and does not meet the Medicare criteria of reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a microprocessor-controlled ankle foot system is 
covered for beneficiaries whose functional level is 3 or above. 
 
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 microprocessor-controlled foot. Our 
reviewer says that criteria are met for this item. Our physician reviewer found that the prosthetist has amply 
and credibly explained the treatment rationale in choosing the foot in question for this very active enrollee. 
Additionally, there has been a change in the physiological condition of the enrollee (significant weight loss) 
and the enrollee is a K3 ambulator. 
 
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 microprocessor-controlled foot have been met. Therefore, we decided that the 
Plan has to pre-approve a microprocessor-controlled foot (L5973).  
 
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 pay for inpatient hospital services provided on November 28, 2022, 
to December 5, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON inpatient hospital services. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says providers were available in the enrollee's 
network that could have performed the services needed.  
 
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 inpatient hospital services provided on November 
28, 2022, to December 5, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services. 
 
You asked the Plan to pre-approve the physical therapy services. You say that the enrollee will benefit from 
skilled physical therapy to improve functional mobility. The Plan denied your request. The Plan says the 
enrollee has reached a plateau in treatment and has no medical need for continuing a professionally supervised 
maintenance program.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy services. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the enrollee has chronic pain but good range of 
motion and some decreased strength and able to continue with a home exercise program. 
 
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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the physical therapy services.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the enrollee needs this treatment. The Plan denied 
your request. The Plan says that the step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. If a Plan decides to apply step therapy requirements to Part B drugs, they must 
disclose that information in the ANOC and EOC documents. The Plan's contract does not indicate that it has 
implemented such criteria for certain Part B medications. 
 
We looked at your contract with the Plan. We did not see where the contract says that the Plan has decided to 
apply step therapy requirements to Part B drugs. This means that the Plan did not follow Medicare rules for 
disclosure of step therapy information. Therefore, we decided that the Plan has to pre-approve Evenity. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stab phlebectomies. 
 
You asked the Plan to pre-approve the stab phlebectomies. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater 
than 4 mm in diameter and if the enrollee remains symptomatic after a six-week trial of conservative therapy. 
 
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 stab phlebectomies. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the patient has not yet 
undergone saphenous vein reflux treatment. 
 
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 stab phlebectomies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the stab phlebectomies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on August 19, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration for 
the services provided. 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 skilled nursing facility 
care provided on August 19, 2022.