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

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1832). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is ambulatory, but the documentation does not reveal evidence of objective knee joint 
laxity or instability on a physical examination. There is no evidence of recent injury/surgery to the knees. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1832).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a gait trainer walker submitted under code E8002 for the enrollee.
You asked the Plan to provide coverage for this equipment. You say that this equipment is medically necessary. The Plan denied your request. The Plan says the equipment is not being requested under the correct code. Maximus overturned the Plans denial stating the equipment is medically necessary. The Plan requested a reopen and stated the issue was not medical necessity but that the provider is not using the correct code. The Plan is attempting to work with the provider to correct this issue.
The Plan must follow Medicare rules. Medicare rules say that providers must request or report services and equipment with the appropriate codes. The Plan notes that code E8002 is an inappropriate code for the requested walker. The Plan is attempting to work with the provider to use the correct code. Therefore, we decided that the Plan does not have to provide coverage for a gait trainer walker submitted under code E8002 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment (TENS unit (E0730 RR KX) provided to the enrollee on November 9, 2022.
You asked the Plan to pay for this claim. You say that this equipment 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 for insufficient claim information in the file. The Plan requested a reopen and provided the required claim information. The Plan notes that the claim history shows claims have been submitted for this TENS unit (E0730 RR KX) stating it is a rented item. The Medicare guidelines state supplies related to this type of equipment are included in the rental allowance; there is no additional allowance for items such as electrodes, lead wires, and batteries. As the provider is renting the unit to the enrollee, the provider should not bill for supplies. It is also noted that the provider has billed the plan for 6 units for code A4595 (Electrical stimulator supplies, 2 lead, per month). Medicare guidance states the usual maximum utilization is: 2 TENS leads - a maximum of one unit of A4595 per month. 4 TENS leads - a maximum of two units of A4595 per month. The provider is billing the units more than the Medicare allowed amount.
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 code. Providers must also bill the appropriate number of units allowed by Medicare.
In this case, this claim could not be paid as billed due to an error with the supplies billed and the number of units billed for this rental item. Therefore, we decided that the Plan does not have to pay for durable medical equipment (TENS unit (E0730 RR KX) provided to the enrollee on November 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 6, 2023, to January 8, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this charge is 
excessive. 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 $295 
copayment per day for days 1-6 of each inpatient hospital stay. Your contract with the Plan also says you then 
pay a $0 copayment per day for days 7-90.  
 You have been asked to pay $171.56, which is less than the standard $295 copayment per day for the inpatient 
hospital stay. This item/service falls within the inpatient hospital care 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 inpatient hospital stay provided from January 6, 2023, to January 
8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from February 15, 2022, to 
May 3, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for chiropractic services. You say that these services were covered in the past. The 
Plan denied your request. The Plan says these services were not authorized. 
 
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 chiropractic services provided from February 15, 
2022, to May 3, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
chiropractor. 
 
You asked the Plan to pre-approve the referral. You say that the requested provider practices a "Directional 
Non-Force" technique that no other chiropractors in the area do.  The Plan denied your request. The Plan says 
the services are not urgent/emergent and are available within the enrollee's network.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the referral. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the plan's 
denial is medically justified on the basis that it is offering adequate care to meet your medical needs through 
referral to an in-network provider. There is nothing unique about your condition that would make it medically 
necessary to see the out-of-network requested provider. Based on the medical records provided the plan has 
shown that they have in-network providers who meet the Standards of Care required for treatment of your 
condition. You are not currently receiving any active treatment and/or medical management of your condition 
that makes it medically necessary for you to continue care with the out-of-network provider as requested.  
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuation of care with an out-of-network (OON) chiropractor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service January 25, 
2023. 
 
You asked the Plan to pay for procedure code 95941. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 95941 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95941 billed for date of service January 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says a ventilator is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 01, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support 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 laboratory services 
provided on February 01, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for out of network diabetic supplies.
You asked the Plan to provide coverage for out of network diabetic supplies. You say that these supplies are medically necessary. The Plan denied your request. The Plan says it is not necessary to obtain these supplies out of network. Maximus overturned the Plans denial stating this equipment is medically necessary. The Plan requested a reopen and stated the issue was not medically necessity but the fact that the requested provider is out of network.
The Plan is correct in this case. 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 Plan contract specifically states diabetic supplies and equipment must be obtained from Plan provider. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. We found no exception that would require the Plan to provide coverage for these items out of network. Therefore, we decided that the Plan does not have to provide coverage for out of network diabetic supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 29, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the doctor's office staff stated that the 
doctor is in-network. The Plan denied your request. The Plan says an opt-out provider cannot bill us, nor can 
we pay you for these services. 
 
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. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided on April 29, 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. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs therapy services to regain full 
function for walking, self-care, and other daily activities. The Plan denied your request. The Plan says that the 
enrollee does not meet the Medicare criteria for admission to an Inpatient Rehabilitation Facility. 
 
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. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
 and benefit from  the intensive rehabilitation therapy program provided in an IRF. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
February 27, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. 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 $45 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $45 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 a specialist office visit provided on February 27, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 31, 2023. 
 
You asked the Plan to pay for psychotherapy. 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 psychotherapy provided 
on January 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87505 for date of service December 20, 
2022, to December 21, 2022. 
 
You asked the Plan to pay for procedure code 87505. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87505 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 3-5 targets. 
 We find that CPT code 87505 is not supported in the medical record. Specifically, the documentation shows 
that the enrollee had a gastrointestinal panel with 22 pathogens tested. There is a more appropriate code to be 
billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of 
procedure code 87505 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87505 for date of service December 20, 2022, to December 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the biopsy procedure provided on March 
01, 2023. 
 
You asked the Plan to waive the copayment for the biopsy procedure. You say that you were told that you 
would not have a copayment. 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 $225 
copayment for in-network outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $225 copayment for the biopsy procedure. This item/service falls within the in-network outpatient surgery, including services provided at hospital outpatient facilities 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 biopsy procedure provided on March 01, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection device (E2311), harness 
(E2313), and an expandable controller (E2377).  
 
You asked the Plan to pre-approve the upgraded electronics. You say that the enrollee does not have the 
required range of motion in her elbow and shoulder girdle to operate separate switches for each actuator. You 
also say that without being able to run the powered seating functions through the joystick which require the 
requested electronics the seating functions which have been previously approved as part of the request for the 
motorized wheelchair the powered seating functions are rendered unusable.  The Plan denied your request. The 
Plan says there is not a medical need to control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does have use of the upper extremities and can operate and control 
the power options using the switches that are included in the basic wheelchair. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection device (E2311), harness (E2313), and an expandable 
controller (E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81294 billed for date of service July 15, 
2022. 
 You asked the Plan to pay for procedure code 81294. The Plan denied your request. The Plan says payment for 
code 81294 is bundled into payment for code 81292. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 81294 
is a column II code to column I code 81292. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81294 billed for date of service July 15, 2022.