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

 
We decided that the Plan does not have to pre-approve an endosteal implant and surgical access to an implant 
body (D6010, D6011). 
 
You asked the Plan to pre-approve 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 your benefit for the requested item or 
service 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 will be exhausted between February 11, 2023, to May 12, 
2023. Therefore, we decided that the Plan does not have to pre-approve an endosteal implant and surgical 
access to an implant body (D6010, D6011).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on August 24, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that the services were medically necessary. 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 wound care supplies 
provided on August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for medical services provided from May 10, 2022, to June 14, 2022.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says you had another insurance carrier at the time who was your primary payor, and they must address the services billed first. Maximus overturned the Plans denial for lack of documentation to show coordination of benefits.
The Plan requested a reopen and provided documentation to show you indeed had a primary payor and that attempts have been made to have them submit an Explanation of Benefits showing they completed their review of these services.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan is correct in this case. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has attempted to work with the primary payor to determine if they have completed their review. Unfortunately, the primary does not appear to have been cooperative with these efforts. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for medical services provided from May 10, 2022, to June 14, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, SNF admission was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan notes that the medical records show the enrollee had not walked often in the past year. The enrollee was noted to be bedridden for the most part and dependent with bed mobility. The enrollee used a lift for transfers and was unable to walk. The enrollee had poor tolerance for activity with limited participation. The records show she was unable to have upright posture upon sitting, was noted to have a plantarflexion contracture on the left foot and required 24-hour care.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. The medical records clearly show the enrollees needs were custodial in nature, which is not covered by Medicare. There was no expectation of improvement from her full assist care requirements with SNF admission. The enrollee did not required daily skilled nursing or daily skilled therapy services at an inpatient SNF level of care. In this case SNF care was not considered medically reasonable and necessary based on Medicare guidelines. Therefore, we decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit provided on January 10, 
2023, to February 23, 2023. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that the services were rendered by 
the primary care physician. 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 $25 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for the specialist visit. This item/service falls within the in-
network physician/practitioner services, including doctors office visits 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. The records show ancillary providers 
are considered a specialists. Therefore, we decided that the Plan does not have to waive the copayment for the 
specialist visit provided on January 10, 2023, to February 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 7, 2022.
You asked the Plan to pay for code 73552 as billed. You say that this claim should be paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed amount by Medicare.
Maximus overturned the Plans denial for a lack of claim information in the case file to show this code was previously billed. The Plan requested a reopen and provided additional claim information. The Plan provided documentation to show the additional units billed for this code.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess units. In this case, the MUE for CPT code 73552 is 3. The MAI value for this code is 3. You did not provide all the required evidence showing that the excess units were provided, were correctly coded, and were medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on August 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on December 30, 2022. 
 
You asked the Plan to pay for wound care. You say that you were not able to verify eligibility and obtain 
authorization. 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 wound care provided on 
December 30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on September 14, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that this 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 physical therapy 
services provided on September 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care.
Our Medical Director states that the complexity of the patient's nursing, medical and rehabilitation needs did not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical records provided do not clarify why the patient requires an intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully participate in and benefit from the 3 hours of therapy a day with the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the services are medically necessary. The Plan denied your request. The Plan says that an IRF admission is not medically necessary, and the enrollee can receive the care they need in other settings. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our Medical Director states that the patient's medical conditions appear unstable with ongoing issues with hypoxia and rapid ventricular response that appear to require further stabilization in the acute hospital setting before discharge to a rehabilitation facility. The patient does require physical therapy and occupational therapy services, but the medical records provided do not clarify that the patient could tolerate 3 hours per day in an intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to his "very tenuous" respiratory status and poor endurance. Our Medical Director found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on December 11, 2022, billed 
with code 93010. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for this code is bundled into payment for 
code 99285. 
 
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 the imaging services provided have 
been met. Specifically, the Plan has not provided medical records to support the services as billed. Therefore, 
we decided that the Plan does not have to pay for imaging services provided on December 11, 2022, billed with 
code 93010.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for the seat lift mechanism provided on 
November 21, 2022. 
 
You asked the Plan to increase the reimbursement for the seat lift mechanism. You say that you did not know 
you would only be reimbursed a small amount of the total cost. The Plan denied your request. The Plan says 
that you were reimbursed the correct amount. 
 
Your contract with the Plan clearly says that if you have already paid for covered services, the Plan will 
provide reimbursement for the Plans share of the cost for those covered services. 
 
The record shows you were reimbursed the full Medicare allowed amount of $314.56 for the seat lift 
mechanism. This item falls within the durable medical equipment benefit category. This means that you have 
been reimbursed the correct amount based on the contract with the Plan. Therefore, we decided that the Plan 
does not have to increase the reimbursement for the seat lift mechanism provided on November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(A4238, E2102). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as you do not meet the clinical 
requirements to be approved. 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies (A4238, 
E2102).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on August 25, 
2022. 
 
You asked the Plan to pay for an office visit and related services. 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 an office visit and 
related services provided on August 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper 
spinal canal. 
 
You asked the Plan to pre-approve the MRI of the upper spinal canal. You say that the enrollee is suffering 
from cervical spine pain and has had an x-ray and done therapy without any success. The Plan denied your 
request. The Plan says a study like the one requested has already been approved for the enrollee. The plan 
needs results of the prior approved study that show the need for repeat imaging, or you must confirm that the 
prior approved study was not performed. 
 
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 the MRI of the upper spinal canal. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found during an encounter on 
March 14, 2023, the enrollee was found to be neurologically intact. The notes reference and electromyography 
(EMG) and nerve conduction studies revealed mild bilateral median nerve neuropathy but no cervical 
radiculopathy. The enrollee had been referred to physical therapy (PT) but did not attend due to Covid and 
insurance issues. There is no reference in the submitted records to an already approved imaging study aside 
from plain x-rays. Due to the enrollee's intact neurological status as well as an EMG which was negative for 
cervical radicular findings and failure to pursue PT as advised, the medical necessity of the requested MRI of 
the cervical spine has not been established in the submitted records. There is no mention of a previously 
approved cross sectional imaging study of the cervical spine in the material submitted for review. 
 
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 MRI of the upper spinal canal have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper spinal canal.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim partial denture (D5820). 
 
You asked the Plan to pre-approve 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 pre-approve an 
interim partial denture (D5820).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
June 21, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were told this 
would be fully covered. 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 ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance transportation. This item/service falls within 
the ambulance services 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 the 
ambulance transportation provided on June 21, 2022.