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

We decided the Plan does not have to pay for imaging services provided to the enrollee on October 7, 2022.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says based on the "21" status code reported for discharge, the enrollee was released to law enforcement due to incarceration. Services billed to incarcerated individuals are not covered by Medicare. Maximus overturned the Plans denial stating the Plan did not provide records to show the enrollee was incarcerated. The Plan requested a reopen and noted that this denial was based on the "21" code reported by the provider and that if the provider reported code "21" in error a corrected claim is required. The Plan notes that the enrollee received claims for two services on October 7, 2022. One of those services is this appealed claim and the other is a facility charge claim billed with a discharge status of 21, which meant the enrollee was in state/local custody at the time of services.

Providers should use the "QJ" modifier for this type of claim. The "QJ" modifier is defined as "Services/items provided to a prisoner or patient in State or local custody, however, the State or local government, as applicable, meets the requirements in 42 CFR 411.4(b)."

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 codes and when necessary, the appropriate modifiers. In this case, a discharge status code of "21" was indicated on the facility claim for services rendered the same day. Either both claims should have reflected an incarceration status or neither claim should reflect an incarceration status if the enrollee indeed was not in custody of state or local authorities. If the enrollee was released to local authorities, the modifier submitted should have been "QJ". Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on October 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on May 31, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the podiatry services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the podiatry services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the podiatry services provided on May 31, 2023, 
by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve root amputation  per root (D3250) and an incisional 
biopsy of oral tissue, hard (bone, tooth) (D7286). 
 
You asked the Plan to pre-approve root amputation and an incisional biopsy of oral tissue. You say that this 
should be covered. The Plan denied your request. The Plan says these are not covered services. 
 
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 root 
amputation  per root (D3250) and an incisional biopsy of oral tissue, hard (bone, tooth) (D7286).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a core build-up (D2950), and local anesthesia in 
conjunction with a dental procedure (D9215) provided on June 26, 2023. 
 
You asked the Plan to pay more for the dental services. You say that all of this dental work was necessary. The 
Plan denied your request. The Plan says these services have been correctly denied. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. D9215 is not a covered dental benefit. Therefore, we decided that the Plan does not have to pay more for a core build-
up (D2950), and local anesthesia in conjunction with a dental procedure (D9215) provided on June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 30, 2023. 
 
You asked the Plan to pay for an office 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 an office visit provided 
on May 30, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ongoing physical therapy. 
 
You asked the Plan to pre-approve the therapy services. You say that ongoing physical therapy is medically 
necessary. The Plan denied your request. The Plan says ongoing physical therapy is not medically necessary.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration your condition. 
Our physician reviewer found the requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain your current condition or to prevent or slow further deterioration. You have met your 
lower extremity strength goal, and the documentation does not support that you require ongoing formal 
physical therapy. You have had instruction in a home exercise program and should be able to transition to an 
independent home exercise program given your history of having 95 therapy visits. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ongoing physical therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of a neurostimulator 
electrode array; of a sacral nerve (transforaminal placement) including image guidance, if performed (64561). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service.  
  
The Plan follows Medicare rules. The rules say that sacral nerve stimulation is covered for the treatment of 
urinary urge incontinence, urgency-frequency syndrome, and urinary retention. 
 
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 this service. Our reviewer says that the 
enrollee does not meet criteria for coverage of the requested service. Our physician reviewer found that the 
enrollee has multiple sclerosis with an overactive bladder and urge incontinence.  
  
 
Percutaneous implantation of a neurostimulator electrode array; of a sacral nerve is not covered when 
incontinence is related to a neurologic condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of a neurostimulator electrode array; of a sacral nerve 
(transforaminal placement) including image guidance, if performed (64561).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a psychotherapy visit to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve a psychotherapy visit. You say that you would like to continue to see your 
psychologist due to mental health issues. The Plan denied your request. The Plan says you must receive 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 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 and is not enrolled in the Medicare 
program. 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 a psychotherapy visit to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (including elevation of a full thickness 
flap and closure)  four or more contiguous teeth or tooth bounded spaces per quadrant (D4260). 
 
You asked the Plan to pre-approve osseous surgery (including elevation of a full thickness flap and closure)  
four or more contiguous teeth or tooth bounded spaces per quadrant (D4260). You say that you do not agree 
with the denial. The Plan denied your request. The Plan says this service is 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. Osseous surgery (including 
elevation of a full thickness flap and closure)  four or more contiguous teeth or tooth bounded spaces per 
quadrant (D4260) is not covered under the Plans dental benefits. 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 
osseous surgery (including elevation of a full thickness flap and closure)  four or more contiguous teeth or 
tooth bounded spaces per quadrant (D4260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for Transcutaneous Electrical Nerve Stimulators (TENS) supplies billed to the enrollee for September 27, 2022.

You asked the Plan to pay for this claim . You say that these supplies should be paid for by the Plan. 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 items that are provided on a recurring basis, suppliers are required to have contact with the enrollee or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary. Based on these guidelines, the Plan has correctly denied the claim for payment as the documentation submitted did not include a valid, documented refill request.

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 records provided do not show there was appropriate contact with the enrollee or that the refill guidelines were followed. Therefore, we decided that the Plan does not have to pay for to pay for Transcutaneous Electrical Nerve Stimulators (TENS) supplies billed to the enrollee for September 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis.  
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the requested imaging is 
necessary to evaluate the enrollee's condition. You would like reconsideration based on the records submitted.  
The Plan denied your request. The Plan says the requested imaging is not reasonable or medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the abdomen and pelvis. 
Our reviewer says that the requested imaging is not medically necessary. Our physician reviewer found an 
abdominal ultrasound has not been performed but has been ordered per the provider. There was an inadequate 
medical evaluation for other causes of loss of appetite and nausea in the enrollee. The review has determined 
that the requested CT scan is not medically reasonable or necessary. 
 
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 CT scan of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay transcutaneous electrical nerve stimulator (TENS) supplies billed with code E0730 for November 12, 2022.

You asked the Plan to pay this claim. You say that these supplies should be paid by the Plan. The Plan denied your request. The Plan says the records provided do not support the claim billed. Maximus overturned the Plans denial. The Plan requested a reopen and stated that code E0730 is not a code associated with TENS unit supplies. The records provided do not show the enrollee is being treated for chronic untraceable pain and/or meets the criteria needed for approval and coverage of a TENS unit. The provider also billed for the shipment of supplies over the maximum quantity allowed by Medicare.

The Plan is correct in this case. 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 medical records to determine if Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay transcutaneous electrical nerve stimulator (TENS) supplies billed with code E0730 for November 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote cardiac monitoring provided on February 23, 2023. 
 
You asked the Plan to pay for remote cardiac monitoring. You say that this was medically necessary and should 
be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for remote cardiac 
monitoring provided on February 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 18, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the enrollee is in a facility and does not have a 
choice with who they see. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network podiatry visit provided on 
February 16, 2023, to June 08, 2023. 
 
You asked the Plan to waive the copayment for an in-network podiatry visit. You say that you did not have this 
copayment in 2022, you feel this is incorrect. 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 $15 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for an in-network podiatry visit. This item/service falls within 
the Physician/Practitioner services, including doctors office visits 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 $45 ($15 copayment x 3 visits 
= $45). Therefore, we decided that the Plan does not have to waive the copayment for an in-network podiatry 
visit provided on February 16, 2023, to June 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an axial rotation unit (L5984) and shank foot system with vertical loading pylon (L5987) for the enrollee.

You asked the Plan to pre-approve an axial rotation unit and shank foot system with vertical loading pylon. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested items are not medically necessary because the enrollee is not a K3 ambulator.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an axial rotation unit and shank foot system with vertical loading pylon. Our Medical Director states that the clinical documentation does not support that the coverage criteria for an advanced foot and ankle were met in this case, as the enrollee's functional level was not 3 or above.

Our Medical Director found that the enrollee's condition does not meet criteria for coverage of an axial rotation unit and shank foot system with vertical loading pylon. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an axial rotation unit and shank foot system with vertical loading pylon have not been met. Therefore, we decided that the Plan does not have to pre-approve an axial rotation unit (L5984) and shank foot system with vertical loading pylon (L5987) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from February 19, 2020, to March 12, 2020.

You asked the Plan to pay for this claim. The Plan denied your request. The Plan says a complete itemized bill was not submitted for review. Maximus overturned the Plans denial for a lack of medical records in the file. The Plan requested a reopen and submitted the medical records as well as a portion of the itemized bill, clearly showing the last five pages were not submitted.

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 Plan could not pay this claim in full due to the omission of a complete itemized bill. The Plan shows several requests were made for this information which were not responded to. Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee from February 19, 2020, to March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) provided on June 
26, 2023. 
 
You asked the Plan to pay for 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 January 10, 2020. 
Therefore, we decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) 
provided on June 26, 2023.