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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that the requested CGM is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the Medicare criteria was not 
met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and related supplies. Our 
reviewer says that the CGM coverage criteria was not met. Our physician reviewer found that the record 
indicates that the enrollee has diabetes. The record provided does not indicate that the enrollee is being treated 
with insulin or has problematic hypoglycemia as defined by the Medicare rules. The elements of the coverage 
criteria are not satisfied. The requested service is not recommended. 
 
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 CGM and related supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified preventive procedure (D1999) and resin (tooth 
colored) fillings (D2392) provided on November 22, 2022. 
 
You asked the Plan to pay for unspecified preventive procedure and resin fillings. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 pay for 
unspecified preventive procedure (D1999) and resin (tooth colored) fillings (D2392) provided on November 
22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased at on April 5, 2022.
You asked the Plan to pay for out of network hearing aids. You say that the Plan should pay for these hearing aids. The Plan denied your request. The Plan says these hearing aids were purchased out of network. Maximus overturned the Plans denial for insufficient claim in formation in the case file. The Plan requested a reopen and noted that on December 14, 2021, you purchased hearing aids from a network provider. On March 30, 2022, you returned the hearing aids, and the records show you were fully refunded on April 20, 2022. The records show you did not contract the Plan prior to purchase of hearing aids on April 5, 2022.
The Plan is correct in this case. Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan only pays for hearing aids purchased from network provider. You purchased hearing aids, a retail hearing provider on April 5, 2022. You did not have prior authorization from the Plan for this purchase and it is not a network provider. Therefore, we decided that the Plan does not have to pay for hearing aids purchased on April 5, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs continued medical management and therapy. The Plan denied your request. The Plan says that the IRF services you are requesting do not meet the requirements for approval.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our Medical Director states that the documentation does not adequately support that the enrollee's nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care, nor was it demonstrated that she would reasonably be expected fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our Medical Director found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chiropractic services provided on 
November 16, 2022. 
 
You asked the Plan to waive the coinsurance for the chiropractic services. You say that you should have been 
reimbursed more money. 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 chiropractic services. 
 
You have been asked to pay 50% coinsurance for the chiropractic services. This item/service falls within the out-of-network chiropractic services 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. The total you owe is $19.16 ($38.32 allowed amount x 50% coinsurance = 
$19.16). Therefore, we decided that the Plan does not have to waive the coinsurance for the chiropractic 
services provided on November 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 21, 2023, to 
February 24, 2023. 
 
You asked the Plan to pay for home health services. You say that you disagree with the denial and request 
reconsideration of payment on this claim. The Plan denied your request. The Plan says the claim must have the 
appropriate type of bill to process. 
 
The Plan follows Medicare rules. We reviewed the file and the Medicare rules. Based on this information, we  
decided that Medicare rules for coverage of the home health services have not been met. The claim was billed  
with an invalid type of bill for a non-participating home health provider, as the type of bill (TOB) on the claim  
is submitted as "323" which is incorrect and should be "329". We find the Medicare rule for payment of this 
February 21, 2023, through February 24, 2023, claim has not been met. If the provider determines that a billing 
error occurred during the initial submission of the denied claim, the Plan will accept a submission of a 
corrected claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for 
home health services provided from February 21, 2023, to February 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  complete denture- maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you need this because your denture split in 
two and you cannot use it. 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 November 3, 2022. 
Therefore, we decided that the Plan does not have to pre-approve  complete denture- maxillary (D5110).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on October 5, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
fainted while golfing and your wife contacted 911. You also say that the ambulance arrived and treated you on 
the scene and you refused transport to hospital since you had already been treated. The Plan denied your 
request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 5, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on October 5, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. You asked the Plan to pre-approve Eylea. You say that denying this medication would be a discontinuation of 
care because the enrollee has been on this medication since 2021. The Plan denied your request. The Plan says 
the notes do not show that the enrollee has failed Avastin or Byooviz. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
age related exudative macular degeneration. The provided records do not indicate that the enrollee has tried and 
failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a 
contraindication to or would have an adverse effect from the plan's preferred step one alternatives. The 
elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the mammogram. We decided that the Plan does 
not have to waive the copayment for the mammogram.  
 
You asked the Plan to waive the copayment for the diagnostic mammogram provided on January 24, 2023. You 
say that you do not understand why this service was not billed as preventative. The Plan says that this cost 
sharing was charged correctly. We decided that the Plan has to reduce the copayment for the mammogram.  
 
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 says that you must pay a $20 
copayment for Medicare-covered x-rays. The Plan says you must pay a $150 copayment for the mammogram. 
Based on the Plan contract however, you cannot be asked to pay more than a $20 copayment for the 
mammogram. Therefore, we decided that the Plan has to reduce the copayment for the mammogram.  
 
We also decided that the Plan does not have to waive the copayment for the mammogram. 
 
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 
copayment for Medicare-covered x-rays.  
 
The diagnostic mammogram falls within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. Based on your contract with the Plan, this means that you are responsible for a $20 
copayment for the mammogram. 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 
mammogram provided on January 24, 2023. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93244 billed for date of service May 16, 
2023.  
 
You asked the Plan to pay for procedure code 93244. You say that the claim was coded correctly. The Plan 
denied your request. The Plan says payment for code 93244 is bundled into payment for code 93248. 
 
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 93244 is a column II code to column I code 93248 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 93244 
billed for date of service May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on June 22, 2023. 
 
You asked the Plan to pay for the nursing facility care. You say that the enrollee was residing in a nursing 
facility when services were 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 the nursing facility care 
provided on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interspinous-interlaminar fusion device. 
 
You asked the Plan to pre-approve interspinous-interlaminar fusion device. You say that it is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. Medicare rules say 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 interspinous-interlaminar fusion device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found interspinous devices are experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of interspinous-interlaminar fusion device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve interspinous-interlaminar fusion device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from January 19, 2023, to February 1, 
2023. 
 
You asked the Plan to pay for SNF care. You say that the SNF services were medically necessary. The Plan 
denied your request. The Plan says the enrollee did not require SNF services. 
 
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. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in an SNF setting. 
 
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 pay for SNF care provided from January 19, 2023, to February 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on May 10, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you went in 
for an MRI that had to be stopped mid service and do not feel you should be responsible for 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 $325 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $325 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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 magnetic resonance imaging (MRI) provided on May 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you were advised by your doctor to 
wear compression stockings and to take pain medication to treat your leg cramps. You also say that they should 
be approved because this is your doctors treatment plan for your leg pain. The Plan denied your request. The 
Plan says per Medicare, the compression stockings requested are not covered. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital inpatient or observation care (99233) 
provided on June 24, 2023, to June 25, 2023. 
 
You asked the Plan to pay for subsequent hospital inpatient or observation care. You say that you disagree with 
the denial and have submitted medical records for review. The Plan denied your request. The Plan says code 
99233 remains 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. 
 
 
 
 
 We asked our coder 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 a subsequent hospital inpatient or observation care. Our 
reviewer says that the service does not meet criteria for payment on this claim. Our reviewer found there is 
insufficient documentation to confirm date of service. Although record documents, "date/time note created: 
June 24, 2023, 09:01:48", with dictation and transcription for same date, confirmation cannot be made for date 
of service, service was provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a subsequent hospital inpatient or observation care have not been met. 
Therefore, we decided that the Plan does not have to pay for subsequent hospital inpatient or observation care 
(99233) provided on June 24, 2023, to June 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement (97597) provided to the enrollee on October 3, 2022.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says that payment is included in the global surgery payment for code 28415. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that the debridement was not billed with a modifier to establish this visit was unrelated to the surgery. The Plan is correct in this case.
The service at issue is within the global surgery period of code 28415 provided on August 16, 2022. We find that the service at issue may be unrelated to the surgical procedure; however, the required modifier to indicate this was not used. As such, the billing rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the debridement (97597) provided to the enrollee on October 3, 2022.