Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 12, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 provided 
on May 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS) unit supplies billed to the enrollee for October 27, 2022

You asked the Plan to pay for this claim. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that the records provided did not include a valid, documented refill request.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for all items that are provided on a recurring basis, suppliers are required to have contact with the enrollee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request. In this case, the documentation provided does not show the provider had a refill request for these supplies. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS) unit supplies billed to the enrollee for October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS) supplies provided to the enrollee on September 20, 2022.

You asked the Plan to pay for these supplies. 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 stating the records show the supplies were delivered. The Plan requested a reopen and stated the issue was not delivery but that the documentation provided with the claim does not show the provider contacted the enrollee or a representative of the enrollee prior to shipping the order as is required by Medicare.

The Plan is correct. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the documentation provided does not show the Medicare billing criteria were met in reference to contacting the enrollee prior to shipment. Therefore, we decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulators (TENS) supplies provided to the enrollee on September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
June 1, 2023, and billed with codes 87481, 87500, 87640, 87652, 87798, 87799, and 87900. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on June 1, 2023, and billed with codes 87481, 87500, 87640, 87652, 87798, 87799, and 87900.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve home health services. You say that you submitted medical records for 
review. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plans network) will not be 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 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 
home health services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mammography provided on February 08, 2023. 
 
You asked the Plan to pay for a mammography. You say that the service was 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 a mammography 
provided on February 08, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from March 27, 2023, to 
April 27, 2023.  
 
You asked the Plan to pay for the psychotherapy. You say that the Plan told you that you have mental health 
coverage under your Plan. You say that you understand that these services were provided out-of-network but 
that the benefit still applies and the services were provided by a licensed provider. The Plan denied your 
request. The Plan says a Licensed Marriage and Family Therapist is not a Medicare eligible provider. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from March 27, 2023, to 
April 27, 2023.
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, transfer to a SNF facility was medically necessary for the enrollee. The Plan denied your request. The Plan says as the enrollee was in an inpatient rehabilitation facility (IRF) and received and covered for continued care. The Plan stated transfer to a lower level of care was not required nor was it appropriate. Maximus overturned the Plans denial stating SNF admission was medically appropriate. The Plan requested a reopen and stated the issue was not medical necessity, as it was agreed the enrollee still required care, but that a transfer was not required. As an IRF facility is a higher level of care than a SNF facility, the enrollee was already receiving care in a facility that would prepare him for transition back to the community.

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 enrollee was receiving IRF facility care at the time of this appeal. The medical records provided did not contain documentation to show the Plans coverage of IRF care was ending. As an IRF facility is a higher level of care than a SNF facility, the enrollee was already receiving an appropriate level of care at the time of the appeal. Requesting SNF coverage as a preemptive plan of treatment based on the enrollee's condition at the end of IRF care was not appropriate as the enrollee had not reached that point in his recovery. 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 provide coverage for skilled nursing facility (SNF) care for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services provided to the enrollee on June 25, 2022.

You asked the Plan to pay for the ER services. You say that the services were medically necessary. The Plan denied your request. The Plan says that the provider is not enrolled with Medicare. Maximus overturned the Plan's decision for insufficient information in the case file. The Plan requested a reopen and provided documentation to show that as of April 20, 2022, the providing physician was in an exclusion status for Medicare claims. 

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

However, there is no record of a private contract between the provider and the enrollee to accept services by the rendering physician. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services provided to the enrollee on June 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two 2D oral images (D0350) provided on June 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 was exhausted on date of service June 19, 2023. Therefore, 
we decided that the Plan does not have to pay for two 2D oral images (D0350) provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for the ultraviolet light therapy provided 
on April 6, 2023. 
 
You asked the Plan to increase the reimbursement for the ultraviolet light therapy. You say that you want to be 
reimbursed the entire cost of the procedure. The Plan denied your request. The Plan says you were reimbursed 
the correct amount. 
 
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 you must pay 10% coinsurance for doctor and other health care provider 
services.  
 
 You have been asked to pay $2.89, which is 10% coinsurance of the allowed amount for the ultraviolet light 
therapy ($28.89 allowed amount x 10% coinsurance = $2.89). This item/service falls within the doctor and 
other health care provider services benefit category. You have been reimbursed $26, which is the Medicare 
allowed amount minus the coinsurance amount ($28.89 allowed amount - $2.89 coinsurance = $26). This 
means you have been reimbursed the correct amount. Therefore, we decided that the Plan does not have to 
increase the reimbursement for the ultraviolet light therapy provided on April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) provided on January 19, 2023.

You asked the Plan to waive the copayment for the MRI. You say that you are protected from cost shares like this. The Plan denied your request. The Plan says that these services must be addressed under your Medicaid benefit by your provider. Maximus overturned the Plans denial.

The Plan requested a reopen and provided additional information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible.

The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services). These services qualified under the Medicaid coverage.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) provided on January 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiological services provided to the enrollee on November 28, 2022, billed under Claim A and code 71045.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and stated that this claim denied because the enrollee was not in an inpatient status for this date of service. According to our review, the member was outpatient status during this service. The provided the appealed claim that shows the Place of Treatment as 21 for Inpatient Hospital and the another referring claim for dates of service November 26, 2022, through November 28, 2022, that shows the Type of Bill as 131 for Outpatient Hospital. The appealed claim was not billed with an admission date and the member was in Outpatient Observation Care, not Inpatient status.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

Providers must report services with the appropriate type of bill code or place of treatment code. In this case, the Plan has provided documentation to show this claim was not billed with an appropriate place of treatment or type of bill code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for radiological services provided to the enrollee on November 28, 2022, billed under Claim A and code 71045.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87635, 87502, 87503, 87486, 87541, 
87581, 87651, and 87798) provided on July 5, 2023. 
 
You asked the Plan to pay for the panel testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87635, 87502, 87503, 87486, 87541, 87581, 87651, and 87798 are not supported in the 
medical record. Specifically, a panel was performed and there is a more appropriate singular code for the 
services. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the panel testing (87635, 87502, 87503, 
87486, 87541, 87581, 87651, and 87798) provided on July 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on June 5, 2023. 
 
You asked the Plan to pay for the office visit provided by a chiropractor. You say that you were not aware the 
first visit would not be covered. The Plan denied your request. The Plan says this is not a covered chiropractic 
service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on June 5, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 48-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation. The 
Plan denied your request. The Plan says you have exceeded your transportation limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
48-trip limit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for - Transcutaneous Electrical Nerve Stimulators (TENS) supplies billed to the enrollee for December 1, 2022.

You asked the Plan to pay for this claim. You say that these supplies should be covered by the Plan. 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 noted that for items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary. Per the Medicare guidelines, the Plan has correctly denied the claim for payment as the documentation submitted did not include a valid, documented refill request.

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, the documentation provided does not show the required Medicare guidelines were followed prior to shipping these supplies. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for to pay for - Transcutaneous Electrical Nerve Stimulators (TENS) supplies billed to the enrollee for December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 13, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. 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 provided 
on September 13, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a cervical and vaginal cancer screening (G0145) provided on January 12, 2023.

You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says this benefit was not available at the time of service. Maximus overturned the Plans denial for no medical records. The Plan requested a reopen and noted based on the code used by the provider, no medical records were required for this type of screening.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says one cervical or vaginal exam and testing is covered every 24 months unless a high risk of cancer is noted. You provider billed this claim with code G0145. This is defined as a screening pap smear for a Medicare patient who has no symptoms and is not reported to be at high risk. It should also be noted that the previous testing in 2021 was also code G0145, with no indications of symptoms or high risk. As you had this test previously on December 8, 2021, payment for this test again was not eligible until December 9, 2023 or 24 months.

Therefore, we decided that the Plan does not have to pay for a cervical and vaginal cancer screening (G0145) provided on January 12, 2023.