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

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on July 17, 
2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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 $270 
copayment for outpatient surgery/other outpatient procedures. 
 
You have been asked to pay a $270 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/other outpatient procedures 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. However, since the allowed amount is less than the standard 
copayment, you only owe $219.82. Therefore, we decided that the Plan does not have to waive the copayment 
for an outpatient surgery provided on July 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a tray (E0950), lateral trunk or hip support (E0956), shoulder
harness/straps or chest strap (E0960), and retractable or removable mounting hardware for joystick (E1028)
provided to the enrollee on September 22, 2022.

You asked the Plan to pay for these items. You say that the enrollee's family paid for the modifications to the
enrollee's wheelchair with the expectation of being reimbursed. The Plan denied your request. The Plan says
that these accessories are not covered by Medicare. Maximus overturned the Plan's denial. The Plan requested
a reopening and stated that sufficient information was not submitted. The Plan is correct in this case. 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 these items have been met. There are
no medical records provided to show the enrollee meets criteria for coverage. Therefore, we decided that the
Plan does not have to pay for a tray (E0950), lateral trunk or hip support (E0956), shoulder harness/straps or
chest strap (E0960), and retractable or removable mounting hardware for joystick (E1028) provided to the
enrollee on September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an endoskeletal knee-shin system (L5828, L5845, L5848 and L5856) for the enrollee. 

You asked the Plan to provide coverage for an this prosthetic equipment. You say that at the time of the appeal, this prosthetic equipment was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria for this equipment were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the provider's notes do not present a valid reason why a mechanical knee cannot be used for the enrollee's prosthesis, especially given the weight a microprocessor knee and the enrollee's comorbidities. Providers notes do not give any medical reason why a mechanical K3 knee will not meet the enrollee's need, especially as an initial knee. The Plan also states a microprocessor knee weighs more than a mechanical knee. A microprocessor knee is more prone to damage and corrosion, especially when exposed to water. A microprocessor knee requires more maintenance, such as maintenance of charge for the battery, and avoidance of water. The medical records do not show why this would be reasonable and necessary for this enrollee's initial knee.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 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 this prosthetic equipment have been met. Therefore, we decided that the Plan does not have to provide coverage for an endoskeletal knee-shin system (L5828, L5845, L5848 and L5856) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper complete denture (D5110) and lower complete
denture (D5120).

You asked the Plan to pre-approve these services. You say that you have not used your dental benefits. 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 Plan's coverage rules apply in this case. The Plan covers up to $1,000
for supplemental dental benefits per year. Though the Plan offers a dental benefit in excess of Medicare
coverage, certain limitations apply. The previous determination stated that the Plan did not provide sufficient
evidence to support that you had used the full $1,000 benefit maximum for routine dental.

The Plan has submitted new documentation to support that your annual maximum had already been met prior
to the services at issue. The record shows your benefit for the requested item or service was exhausted on
February 7, 2023. On this date, you received a procedure called alveoloplasty to 24 total teeth, for a total of
$1,428. Therefore, we decided that the Plan does not have to pre-approve an upper complete denture (D5110)
and lower complete denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued coverage of the Negative Pressure Wound 
Therapy (NPWT) Pump (E2402) provided May 25, 2023, through June 25, 2023. 
 
You asked the Plan to pay for the durable medical equipment (DME). You say that the Negative Pressure 
Wound Therapy Pump provided on June 25, 2023, was medically necessary. The Plan denied your request. The 
Plan says the enrollee did not meet criteria for continued coverage of the Negative Pressure Wound Therapy 
Pump provided on June 25, 2023. 
 
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 pay for the durable medical equipment (DME). Our 
physician reviewer found the enrollee is a male with a stage IV ischial pressure wound that was treated with 
conservative treatment and Negative Pressure Wound Therapy Pump for 4 months. This is a request for 
continued use of the pump provided on June 25, 2023. However, as the enrollee had already completed 4 
months of use of the device, an extension is not supported. The enrollee does not meet the LCD criteria for the 
continued use of the provided Negative Pressure Wound Therapy Pump for date of service June 25, 2023. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pay for continued coverage of the Negative Pressure Wound Therapy 
(NPWT) Pump (E2402) provided May 25, 2023, through June 25, 2023.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an advanced electronic knee/foot feature for a
prosthetic leg (L5828, L5845, L5848, L5981, L5982) for the enrollee.

You asked the Plan to provide coverage for this prosthetic equipment. You say that at the time of the appeal,
this prosthetic equipment was medically necessary. The Plan denied your request. The Plan says the medical
records do not support the equipment requested is medically appropriate. Maximus overturned the Plans denial.
The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the
enrollee's physician alleges that K3 foot and microprocessor knee is indicated. However, this is not consistent
with available medical history. The medical records show the enrollee uses a cane. The enrollee has a 15-
degree hip flexion contraction. This is not consistent with K3 ambulation. This cannot be reconciled with
alleged need for K3 prosthesis, including microprocessor knee (MPK). The vendor and the physician do not
show why enrollee requires a microprocessor knee which is heavier, more prone to corrosion and damage
(particularly water damage allegedly wanting to use the prosthesis for outdoor activity) and requires daily
charging. Medicare covers items that meet, but do not exceed, the enrollee's need. The medical records
provided do not demonstrate why the enrollee requires a microprocessor knee, or why another knee will not
meet the enrollee's needs. The Plan states the medical records do not demonstrate that the enrollee is a K3
ambulator.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. 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 this
prosthetic equipment have been met. The statements made by the vendor and the physician are not consistent
with the actual medical records. Therefore, we decided that the Plan does not have to provide coverage for an
advanced electronic knee/foot feature for a prosthetic leg (L5828, L5845, L5848, L5981, L5982) for the
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation provided on June 
05, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation. You say that this service is 
supported in the records proving medical necessity. 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 home or residence visit 
for the evaluation provided on June 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on June 20, 2023. 
 
You asked the Plan to pay for the home 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 the home visit provided 
on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anticoagulant management services provided on July 28, 
2023. 
 
You asked the Plan to pay for the anticoagulant management services. 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 the anticoagulant 
management services provided on July 28, 2023.
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 services are medically necessary for the enrollee
to receive the level of care needed to restore function and ensure a safe discharge to the community. The Plan
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.

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 the enrollee does not require treatment by multiple therapies. While the medical
record supports a need for physical or occupational therapy, there is no documented need for intensive
rehabilitation services. Medically necessary care can be provided in a different level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0480 billed for date of service July 19, 
2023.  
 
You asked the Plan to pay for procedure code G0480. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code G0480 is bundled into payment for code 80307.  

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 G0480 
is a column two code to column one code 80307 with a modifier indicator of 0. The column two 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 G0480 billed for date of service July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power
options (K0861) and attachments for the enrollee.

You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options and attachments.
You say that these items are medically necessary. The Plan denied your request. The Plan says that the enrollee
does not have medical need for multiple power options included with K0861 Group 3 power wheelchair.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Group 3 power
wheelchair with multiple power options and attachments. Our Medical Director states that the clinical
documentation does not support that the enrollee in this case meets criteria for a Group 3 power wheelchair
with multiple power options. The documentation does not support that the enrollee is at high risk for skin
breakdown and requires power tilt and power recline. There is no documentation of a pressure ulcer currently,
and there is no history of flap surgery. The enrollee does not self-catheterize. She is not on antispasmodic
medication. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of a
Group 3 power wheelchair with multiple power options and attachments.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Group 3 power wheelchair with multiple power options and attachments have
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair
with multiple power options (K0861) and attachments for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network durablemedical equipment 
(DME) provided on September 30, 2022. 
 
You asked the Plan to waive the coinsurance for out-of-network durablemedical equipment (DME). You say 
that you disagree with the coinsurance. 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 50% 
coinsurance for out-of-network durable medical equipment (DME). 
 
You have been asked to pay 50% coinsurance for out-of-network durablemedical equipment (DME). This 
item/service falls within the out-of-network durable medical equipment (DME) 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 out-of-network durablemedical equipment (DME) provided on 
September 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care and the debridement provided on 
April 25, 2023. 
 
You asked the Plan to pay for the nursing facility care and the debridement. You say that 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 the nursing facility care 
and the debridement provided on April 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 2, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Furthermore, procedures 
shall be reported with the most comprehensive Current Procedural Terminology (CPT) code that describes the 
services performed. Providers/suppliers must not unbundle the services described by a Healthcare Common 
Procedure Coding System (HCPCS)/CPT code. Therefore, we decided that the Plan does not have to pay for 
lab services provided on May 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on May 17, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that this service is supported in the 
records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
related services provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on July 26, 2023. 
 
You asked the Plan to pay for home 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 home visit provided on 
July 26, 2023.