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

 
We decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0667) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compression devices. You say that the requested items are a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage for OON services 
have not been met. 
 
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 
pneumatic compression devices (E0652, E0667) 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 imaging services provided on June 13, 2022, billed with code 
72110. 
 
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 this code is bundled into payment for another 
code. 
 
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, this is a corrected claim and was submitted without the original Explanation of benefits 
for the prior billed claim. Therefore, we decided that the Plan does not have to pay for imaging services 
provided on June 13, 2022, billed with code 72110.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says an acute inpatient hospital admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
  
 
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 acute inpatient hospital care. Our 
reviewer says that the requested services are not medically necessary. Our physician reviewer found that the 
enrollee was approved for an elective cervical fusion surgery with implants and an allograft for spondylosis. 
This is a request for inpatient services related to this procedure. However, there wasn't sufficient support made 
for an inpatient status following this typically ambulatory procedure. The enrollee's medical history and recent 
documentation describes no unstable condition or high risk factors that would expect a prolonged complex 
recovery which might warrant an inpatient stay. Therefore, inpatient services will be considered not medically 
necessary at this time. Reassessment for an inpatient need can follow the surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate upper denture (D5130) and the immediate 
lower denture (D5140) provided on November 4, 2022. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these items are not covered under your 
supplemental dental policy. 
 
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 items provided are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the immediate upper 
denture (D5130) and the immediate lower denture (D5140) provided on November 4, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that we did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF care. Our Medical Director states that the documentation does not support that it was medically reasonable and necessary to provide skilled services on a daily basis on an inpatient basis, in a skilled nursing facility setting. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the compound drug provided to the enrollee on March 30, 2022.
You asked the Plan to pay for the compound drug. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says that the claim was not submitted correctly. Maximus overturned the Plan's denial. The Plan requested a reopening and stated we did not apply the correct criteria.
The Plan must follow Medicare rules. Medicare rules say that you must enter the name and total dose (in mg or mcg) of each drug of the refill in Box 19 of the CMS 1500 or the appropriate comment loop of electronic claims and drug doses used in narrative description must be in mgs or mcgs only. We looked at the file and Medicare rules. The claim form submitted confirms not all drugs were submitted in mg or mcg. Based on this information, we decided that Medicare rules for coverage of the compound drug have not been met. Therefore, we decided that the Plan does not have to pay for the compound drug provided to the enrollee on March 30, 2022.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided to the enrollee on April 3, 2022.
You asked the Plan to pay for the physician's services. You say that these services were medically necessary. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on April 2, 2022. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the physician's services provided to the enrollee on April 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99239 billed for date of service March 12, 2022.
You asked the Plan to pay for procedure code 99239. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 99239 is bundled into payment for code 99223.
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 99239 is a column II code to column I code 99223 with a modifier indicator of 0. The column II code is therefore not payable. 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 99239 billed for date of service March 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infusions provided on March 10, 2022.
You asked the Plan to waive the coinsurance for the infusions. You say that you had already paid a $200 copayment for these services and were not made aware of these additional charges. 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the infusions. This item/service falls within the Medicare Part B prescription drugs 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 coinsurance for the infusions provided on March 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 77065 billed for date of service June 29, 2022.
You asked the Plan to pay for procedure code 77065. You say that these services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 77065 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 77065 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 77065 billed for date of service June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a denture for lower arch (D5868) and implants (D6010) for tooth #23 and #26.
You asked the Plan to provide coverage for these dental services. You say that at the time of the appeal, these dental services were necessary. The Plan denied your request. The Plan says the dental x-rays do not show the denture can be held in place and that implants are not covered. Maximus partially overturned the Plans denial for the over denture. 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 dental implants (D6010) for areas 23 and 26, and a mandibular complete overdenture (D5865). The Maximus Dental Reviewer determined that the denture for the lower arch was medically necessary. The Plan requested a reopen and argues the requested overdenture is a special type of denture that uses implants to help keep the denture in place, which is not covered.
The medical records show D5865 correlates with a complete mandibular overdenture after placement of implants. The clinical documentation is limited to an X-ray. The X-ray does not show that the enrollee had implants to hold a complete mandibular implant in place. Based on the limited available documentation submitted, the requested dental services were not medically reasonable and necessary, as implants are not present to hold the overdenture and implants are not covered by the Plans dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items are not among those covered under this benefit. Therefore, we decided that the Plan does not have to provide coverage for a denture for lower arch (D5868) and implants (D6010) for tooth #23 and #26.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital stay provided from October 15, 2021,
to October 22, 2021.
You asked the Plan to pay for the inpatient hospital stay. You say that you do not have a secondary insurance.
The Plan denied your request. The Plan says that this is a workman's compensation case.
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 has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the inpatient hospital stay until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the inpatient hospital stay provided from October 15, 2021, to October 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that the records provided support the need for the use of Keytruda in the enrollee's chemotherapy treatment. The Plan denied your request. The Plan says that Keytruda for stage III squamous non-small cell lung cancer is not FDA approved or listed in the Medicare approved sources. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that we did not apply the correct criteria. Our Medical Director looked at the case file and the reopen request. At issue is coverage for Keytruda. Our Medical Director states that the documentation does not support that the use of Keytruda is FDA-approved for the enrollee's diagnosis, is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal, and is safe and effective and otherwise reasonable and necessary for the enrollee in this case.
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Keytruda. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided August 8, 2021, to August 13, 2021, and billed at the Diagnosis Related Group (DRG) 871.
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. 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. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria.
Our Medical Director looked at the case file and the reopen request. At issue is the DRG downgrade from DRG 871 (Septicemia or severe sepsis without MV > 96 hours with major complication or comorbidity) to DRG 689 (Kidney and urinary tract infections with major complication or comorbidity). The enrollee was a then 77-year-old woman with a medical history that included severe COPD, lung cancer, stroke, and depression, who was admitted to the hospital on August 8, 2021, with concern for urosepsis. They enrollee had recently been started on an antibiotic for a urinary tract infection. She presented to the Emergency Department with metabolic encephalopathy and tachycardia and was answering questions somewhat inappropriately. The enrollee was protecting her airway. She had no focal or lateralizing neurologic deficits. The enrollee had significant tachycardia. Hypoxia was thought to be likely due to COPD and a lung mass. Laboratories were notable for troponin of 192, likely demand ischemia, normal lactic acid, a white count of 20000, a urinalysis which was suggestive of infection. Lactic acid was elevated on August 9, 2021, and August 10, 2021. The platelet count, CO2, BUN, creatinine, and bilirubin were not significantly altered. A CT of the chest was negative for PE and showed apparent progression of a likely pulmonary malignant lesion. CT of the head was unremarkable for acute process. Patient was admitted for antibiotics and fluids for treatment of metabolic encephalopathy, possible UTI with leukocytosis. There was no evidence of meningeal signs at the time of admission. The additional information submitted by the plan supports the DRG downgrade from 871 to 689. The case file does not contain sufficient documentation that would support DRG 871. The medical records do not demonstrate that there was significant thrombocytopenia, hypotension, or significant renal or hepatic dysfunction to suggest that a dysregulated host response to infection was present in this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided August 8, 2021, to August 13, 2021, and billed at the Diagnosis Related Group (DRG) 871.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (second stage 
implant surgery) (D6011) Tooth #22, 24 and 27, custom fabricated abutment  includes placement (D6057) and 
abutment supported porcelain/ceramic crown (D6058) x4. 
 
You asked the Plan to pre-approve the dental services. You say that the services should not have been denied. 
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. This benefit includes the 
requested surgical access to an implant body (second stage implant surgery) (D6011) but is limited to 
restorative services  three every 12 to 84 months depending on type of service. Custom fabricated abutment  
includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058) are not covered under 
the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6057 and D6058 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
custom fabricated abutment  includes placement (D6057) and abutment supported porcelain/ceramic crown 
(D6058) x4. 
 
We looked at the file, the Plans rules, and Medicares rules. You have been pre-approved for covered surgical 
access to an implant body (second stage implant surgery) (D6011) Tooth #13, 14 and 22. Therefore, this 
benefits were exhausted. Therefore, we decided that the Plan does not have to pre-approve surgical access to an 
implant body (second stage implant surgery) (D6011) Tooth #22, 24 and 27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010), implant /abutment supported fixed denture for edentulous arch  maxillary (D6114) and implant 
/abutment supported fixed denture for edentulous arch  mandibular (D6115). 
 
You asked the Plan to pre-approve dental services. You say that the enrollee would like the services to be 
considered a medical benefit. The Plan denied your request. The Plan says these services are not covered under 
your Plan. 
 
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. The following services, 
D6010, D6114 and D6115 are not covered under the Plans dental benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6010, D6114 and 
D6115 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve surgical placement of implant body: endosteal implant (D6010), implant /abutment supported 
fixed denture for edentulous arch  maxillary (D6114) and implant /abutment supported fixed denture for 
edentulous arch  mandibular (D6115).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a deep sedation/general anesthesia (D9222). 
 
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 a 
deep sedation/general anesthesia (D9222).