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

 
We decided that the Plan does not have to pay for the traction equipment (E0849), provided on May 25, 2023. 
 
You asked the Plan to pay for the traction equipment. You say that the item should be covered. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication this item was needed, discussed, or ordered in the clinical documentation submitted. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the traction equipment (E0849), 
provided on May 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of malignant lesion including margins (11643) 
and intermediate repair (12051) provided on August 24, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the surgical services. You say that the provider's tax identification number is a 
participating provider for the enrollee's Plan. You say that the provider is only nonparticipating with the 
Medicaid side. You also say that this should be reprocessed and paid. 
 The Plan denied your request. The Plan says prior authorization was not obtained. 
 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 excision of malignant lesion including margins 
(11643) and intermediate repair (12051) provided on August 24, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99203-25 billed for date of service March 6, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the services can be billed together with the 
appropriate modifier. The Plan denied your request. The Plan says the code is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99203-25 is not supported in the medical record. The records show that a new patient 
office visit was provided. During this visit, the enrollee received minor nail procedures, coded 11721 and 
11055.  The records do not show that the office visit was a separately identifiable evaluation and management 
service. Based on this information, we decided that Medicare rules for coverage of the billed service have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 99203-25 billed for date 
of service March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for refraction provided on July 31, 2023. 
 
You asked the Plan to pay for refraction. You say that you are requesting reconsideration for the denied claim. 
The Plan denied your request. The Plan says all subsequent refractions are not covered.  
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for refraction provided on July 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for an LTACH admission. 
 
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 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. 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 Plan. Given there are offered alternatives, an LTACH transfer is 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the enrollee does not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found the enrollee has a history of atrial fibrillation, there is no documentation 
provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for 
an ILR. In summary, there is insufficient documentation to support the medical necessity for insertion of an 
ILR in the enrollees clinical management. 
 
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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: SNF
Decision: Unfavorable

We decided 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 care 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 stating Maximus did not apply the correct
criteria.

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.
Based on the medical records provided, at the time of the appeal, the enrollee had received ongoing therapy
from January of 2023 to May of 2023 with no improvement in function. As of May 2023, the enrollee remained
at maximum assist for bed mobility and was unable to attempt sit to stand function. The enrollee was dependent
for transfers and did not require daily skilled nursing or daily skilled therapy services at an inpatient SNF level
of care. At the time of the appeal, the enrollee was at a custodial level of care which is not covered by
Medicare. Therefore, we decided that the Plan does not have to provide coverage for skilled nursing facility
(SNF) care for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital care to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve inpatient hospital car. You say that this service is supported in the records 
proving medical necessity. The Plan denied your request. The Plan says this is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
inpatient hospital care to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custodial care provided on May 4, 2023, to May 31, 2023. 
 
You asked the Plan to pay for custodial care. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says Medicare does not cover custodial care. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for custodial care 
provided on May 4, 2023, to May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for practitioner services provided on January 24, 2023, and
billed with code 99100.

You asked the Plan to pay for code 99100. The Plan denied your request. The Plan says the Medicare billing
criteria were not met. The Plan follows Medicare rules. Medicare rules say that the Physician Fee Schedule
Status Indicator B means that payment for covered services is always bundled into payment for other services.
Code 99100 has a status indicator B and is not separately payable. Therefore, we decided that the Plan does not
have to pay for the services described by procedure code(s) 99100.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee meets and/or exceeds the 
requirements for LTACH level of care. The Plan denied your request. The Plan says the enrollee does not meet 
all the requirements for an LTACH admission. 
 
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 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 have complex wound care needs, nor does the enrollee require 
ventilator weaning, therefore, the LTACH services are 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 for date of service April 24, 2023. 
 
You asked the Plan to pay for procedure code 99204. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 20610 
provided on the same date of service. We find that the service at issue may be unrelated to the surgical 
procedure; however, the required modifier to indicate this was not used. As such, the billing rules for these 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99204 
for date of service April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the electrocardiogram (EKG) (93010) and 
outpatient visit (99214) provided from September 7, 2022, to March 8, 2023. 
 
You asked the Plan to waive the cost share for the EKG and outpatient visit. You say that you are disputing the 
$100.55. You say that you feel you are being billed twice. You say that you have never had to pay a facility 
claim before. You also say that you do not agree with the charge for September 7, 2022. 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 outpatient diagnostic tests and 
therapeutic services.  
 
The EKG you asked the Plan to waive the cost share for falls within the outpatient diagnostic tests and 
therapeutic services benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $500 deductible for 2022 which applies to outpatient diagnostic tests and therapeutic 
services. The outpatient visit you asked the Plan to waive the cost share for falls within the outpatient hospital services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $500 deductible for 2023 which applies to outpatient hospital services. This cost sharing is a contractual 
obligation that had not been met at the time the EKG was received on September 7, 2022, and the outpatient 
visit was received on March 8, 2023.  Therefore, we decided that the Plan does not have to waive the cost share 
for the electrocardiogram (EKG) (93010) and outpatient visit (99214) provided from September 7, 2022, to 
March 8, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF care was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial as no medical records were submitted in the file. The Plan requested a
reopen and submitted the required medical records.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

The medical records show this 93-year-old enrollee presented with significant weakness and overall
deconditioning limiting mobility and activity tolerance. The medical records show skilled therapy was
recommended for strengthening and mobility. The records state the enrollee used a roller walker and was able
to ambulate 100 feet with walker. The enrollee lived alone and was stated to be independent with daily
activities. The medical records do not show the enrollee was expected to be able to participate in or benefit
from physical therapy at a level of three hours per day for five days a week. Medicare rules for coverage of IRF
care were not met at the time of the appeal. Therefore, we decided that the Plan does not have to provide
coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter (E0118). 
 
You asked the Plan to pre-approve a knee scooter. You say that the item is medically necessary. The Plan 
denied your request. The Plan says a knee scooter is not a covered item. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee scooter have not been met. Specifically, this item is not a covered benefit of Medicare or 
the Plan.  Therefore, we decided that the Plan does not have to pre-approve a knee scooter (E0118).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment and response without transport services 
received on April 22, 2023. 
 
You asked the Plan to pay for ambulance treatment and response without transport services. You say that you 
had a seizure and hit your head while at the store and they called the ambulance, and you did not feel like it 
was necessary to go to the hospital. The Plan denied your request. The Plan says without transport there are no 
payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 22, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment and response without 
transport services received on April 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on March 25, 2023, billed with 
procedure code 73630-26-LT. 
 
You asked the Plan to pay for the imaging service provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 13, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the imaging service provided have not been 
met. Therefore, we decided that the Plan does not have to pay for imaging services provided on March 25, 
2023, billed with procedure code 73630-26-LT.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for admin of eye drops provided on April 15, 2023, to May 1, 
2023. 
 
You asked the Plan to pay for admin of eye drops. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the services obtained by the enrollee were received 
from a provider who is not under contract with the Health Plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services from either Medicare or a Medicare beneficiary, a provider or supplier must be enrolled in the 
Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of admin of eye drops have not been met. Therefore, we decided that the Plan does not have to pay 
for admin of eye drops provided on April 15, 2023, to May 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite (D2393) for tooth #14. 
 
You asked the Plan to pre-approve the dental service. You say that your dentist does not do silver fillings 
anymore and you would like the resin-based composite to be approved. The Plan denied your request. The Plan 
says the denial of authorization for the resin-based composite is correct, because white fillings on posterior 
teeth will be processed as a silver filling; therefore, the approval for the amalgam was appropriate. 
 
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. 
 
  You have been asked to pay the difference between the approved silver filling and white filling along with the 
coinsurance. 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 pre-approve a resin-based composite (D2393) for tooth 
#14.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and related supply 
allowance provided by an out-of-network provider on June 7, 2023. 
 
You asked the Plan to pay for the CGM and related supply allowance. You say that you have send the medical 
records for the claim to be paid. The Plan denied your request. The Plan says the documentation requirements 
have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. There is no information on the proof of delivery to tie it 
to the packing slip to verify what was delivered to the enrollee. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for a continuous glucose monitor (CGM) and related supply allowance provided by an out-of-
network provider on June 7, 2023.