Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on November 28, 2022. 
 
You asked the Plan to pay for the panel testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel testing have not been met. Specifically, the service at issue is a test panel which was unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the panel testing provided on November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says a pneumatic compression 
device is not covered by Medicare to prevent deep vein thrombosis. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you submitted documentation 
for reconsideration of payment. The Plan denied your request. The Plan says Medicare does not separately pay 
for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre diabetic supplies. 
 
You asked the Plan to pre-approve Freestyle Libre diabetic supplies. You say that you would like this brand of 
supplies. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for Freestyle Libre diabetic supplies. Therefore, we decided that the Plan does not have to pre-approve 
Freestyle Libre diabetic supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PalinGen or PalinGen XPlus, per sq cm for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that there have been no failed attempts at conservative therapy. Maximus overturned the Plan's denial. The Plan requested a reopening 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 PalinGen or PalinGen XPlus. Our Medical Director states that the documentation does not support that PalinGen or PalinGen XPlus were medically reasonable and necessary for the enrollee in this case. It was not demonstrated that the enrollee's wound had failed to respond to conservative wound care. Rather, the documentation supports that the wound at issue was healing. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve PalinGen or PalinGen XPlus, per sq cm for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) rendered on 
December 27, 2022. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not show screening test results which are positive or inconsistent with prescription 
medications, dosing schedules, or history and expected results. 
 
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 pay for 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 review has determined that the enrollee does not meet the criteria for this testing. The enrollee 
did not need 22+ drug classes tested. 
 
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 pay for drug testing services (procedure code G0483) rendered on December 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from 
March 11, 2022, to March 13, 2022. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you have not had to 
pay this much for a hospital stay. 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 $300 
copayment each time you are admitted to an acute care hospital. 
 
 You have been asked to pay a $300 copayment 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 reduce the copayment for the 
inpatient hospital stay provided from March 11, 2022, to March 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for code provided on March 03, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that per Medicare guidance, providers are only required to include the "AS" with the 82 modifiers if services are Rendered in a Method II CAH as stated in Medicare Claims processing Manuel Chapter 4 Section 250.9. Procedures billed with the assistant-at-surgery physician modifiers -80, -81, -82, or the "AS" modifier for physician assistants, nurse practitioners and clinical nurse specialists, are subject to the assistant-at-surgery policy. Plans are to pay claims for procedures with these modifiers only if the services of an assistant-at-surgery are authorized. Providers should use the "82" modifier when the assistant at surgery service was provided by a physician and there was not a qualified resident available. Documentation must include information relating to the unavailability of a qualified resident in this situation. Providers are to use the modifier "AS" for assistant at surgery services provided by a physician's assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). The provider must accept assignment. Per these guidelines, the claim denied correctly.
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.
In this case, this claim could not be paid as billed due to the omission of the appropriate modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for code provided on March 03, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve walker to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve walker. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the Medical Benefits Chart (also referred to as the plan's Schedule of 
Copayments/Coinsurance) included with this Evidence of Coverage lists the services the plan 
covers and what the enrollee pays out-of-pocket for each service. 
 
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 
walker to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97166, 92523, 92610, 97110, 97116, 97161, 97530 and 97535) provided from May 6, 2022, to May 20, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and demonstrated that per Medicare Claims Processing Manual Chapter 5, 20.1 - Discipline Specific Outpatient Rehabilitation Modifiers - All Claims: Contractors edit institutional claims to ensure the following: - that a GN, GO or GP modifier is present for all lines reporting revenue codes 042X, 043X, or 044X. Contractors return to the provider institutional claims that do not meet one or more of these conditions. The provider did not meet the condition of adding modifier GN, GO or GP to line 15 code 97166 which would cause the Plan to return claim to the institutional provider. Per the above Medicare guidelines, the Plan has correctly denied the claim for payment.
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 modifiers. In this case, this claim could not be paid due to the omission of the required modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97166, 92523, 92610, 97110, 97116, 97161, 97530 and 97535) provided from May 6, 2022, to May 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953), a guided tissue 
regeneration (D4266), and a cone beam CT capture (D0364). 
 
You asked the Plan to pre-approve D7953, D4266, and D0364. You say that you would like these services 
covered. The Plan denied your request. The Plan says the requested dental services are not covered 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 
bone replacement graft (D7953), a guided tissue regeneration (D4266), and a cone beam CT capture (D0364).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - mandibular (D5120) and complete 
denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 August 23, 2021. 
Therefore, we decided that the Plan does not have to pre-approve complete denture - mandibular (D5120) and 
complete denture - maxillary (D5110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the chest with 
contrast provided on December 12, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the computed tomography (CT) scan with contrast. You say that this service was 
medically necessary. The Plan denied your request. The Plan says enrollees must receive their care from a 
network provider. 
 
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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the computed tomography (CT) scan of the chest with 
contrast provided on December 12, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that you have swelling in your ankles. 
The Plan denied your request. The Plan says the compression stockings requested have been correctly denied. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 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 A6533.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110, 97112, 97116, 97530, 97535 and 97166) provided from July 4, 2022, to July 30, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and noted that per the Medicare Claims Processing Manual Chapter 5, section 20.1, Discipline Specific Outpatient Rehabilitation Modifiers, All Claims, contractors edit institutional claims to ensure the following: that a GN, GO or GP modifier is present for all lines reporting revenue codes 042X, 043X, or 044X. Contractors return to the provider institutional claims that do not meet one or more of these conditions. As stated in the guideline, the provider did not meet the condition of adding modifier GN, GO or GP to line 65 code 97166 which would cause the Plan to return claim to the institutional provider. Per the Medicare guidelines, the Plan correctly denied the claim for payment.
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. The claims omission of the appropriate modifier does allow the Plan to return the entire claim as stated in the Medicare rule. Therefore, we decided that the Plan does not have to pay for therapy services (97110, 97112, 97116, 97530, 97535 and 97166) provided from July 4, 2022, to July 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the health club membership provided from 
January 1, 2023, through April 21, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because the membership purchased in this 
case is not a covered benefit. Specifically, the Plans contract states that coverage is provided for a fitness 
membership through the Plans select fitness provider. However, in this case, you purchased a gym 
membership from an out-of-network provider.   
 
Additionally, the Plans contract states that enrollees receive $300 every three months on a Flex card that may 
be utilized for qualifying fitness expenses which includes fitness centers, gyms, and athletic centers. Therefore, 
we decided that the Plan does not have to issue reimbursement for the health club membership provided from 
January 1, 2023, through April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6751), and a pontic (D6241). 
 
You asked the Plan to pre-approve D6751 and D6241. You say that your front tooth is missing. The Plan 
denied your request. The Plan says the denied dental services are not covered 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 
retainer crown (D6751), and a pontic (D6241).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for code 99213 billed to the enrollee for August 11, 2022.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan demonstrated that the enrollee received services on May 25, 2022, coded as 28285. This code has a 90-day global period. The claim submitted on August 11, 2022, for code 99213 was denied as it was within the 90-day global period. It is also noted that on January 24, 2023, the provider submitted a corrected claim adding the 24 modifier to the claim. The plan paid the provider for this claim on February 9, 2023.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the original claim was not billed with the appropriate modifier due to its 90-day global association with code 28285. It is noted a corrected claim was submitted and paid. Therefore, we decided that the Plan does not have to pay for code 99213 billed to the enrollee for August 11, 2022 as originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM.  
 
You asked the Plan to pre-approve a therapeutic CGM. You say that the enrollee would benefit from a a 
therapeutic CGM. The Plan denied your request. The Plan says the enrollee does not meet criteria. 
 
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 a therapeutic CGM. Our physician 
reviewer found the enrollee is not taking insulin and is not having low blood sugar and we are not told why 
finger stick blood sugar check would not suffice for their glucose monitoring needs. CGM criteria coverage has 
not been met. 
 
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 therapeutic CGM have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a therapeutic CGM.