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

We decided that the Plan does not have to pay for the infusion supplies not used with external infusion pump (A4223) provided to the enrollee on August 24, 2022, and August 25, 2022.
You asked the Plan to pay for these supplies. You say that this claim should be paid. The Plan denied your request. The Plan says the records provided do not support the services billed. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that code A4223 has a Status Indicator of X on the Physician Fee Schedule.
This means that procedure code A4223 is statutorily excluded for Medicare claims. Also, the clinical records and claim do not include any documentation of a covered external infusion pump being used with the infusion supplies. The code reported is for supplies not used with an external infusion pump. The coding/billing rules require use of the GY modifier. As such, the drugs and supplies are not covered.
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. Medicare rules also stated providers must use appropriate codes. Based on the records provided, there is insufficient information in the record to determine if Medicare rules for coverage of this claim have been met. In addition, the incorrect code was reported, and a required modifier was not used. Therefore, we decided that the Plan does not have to pay for the infusion supplies not used with external infusion pump (A4223) provided to the enrollee on August 24, 2022, and August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D4910) provided on September 22, 2022.
You asked the Plan to pay for these dental services. You say that these dental services should be covered by the Plan. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plans denial for a lack of claim information in the file. The Plan requested a reopen and provided the required records.
The Plan is correct in this case. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit more than Medicare coverage, certain limitations apply. The record shows your benefit for D4910 was exhausted on February 3, 2022, and May 19, 2022. Therefore, we decided that the Plan does not have to pay for dental services (D4910) provided on September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99358 billed for date of service November 
21, 2022.  
 
You asked the Plan to pay for procedure code 99358. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99358 is bundled into payment for code 99310. 
 
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 99358 is a column II code to column I code 99310 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 99358 billed for date of service November 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 05, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration for the 
denied payment. 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 laboratory services 
provided on December 05, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 87481 billed for date of service February 14, 2023. 
 
You asked the Plan to pay for procedure code 87481. You say that this service was reported correctly and is 
supported in the medical record. The Plan denied your request. The Plan says that this service was not coded 
appropriately. 
 
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, the CPT Code Manual definition of 
code 87481 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe 
technique. 
 
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 procedure code 87481. Our reviewer says that this code is 
supported in the medical record. Our reviewer found the urinary tract infection (UTI) testing did include 
candida species. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87481 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 87481 billed for date of service February 14, 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: 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 if the enrollee is not admitted to rehabilitation soon, 
it will prolong their ability to regain function and mobility. The Plan denied your request. The Plan says the 
IRF services requested do not meet the requirements for approval. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital stay provided on December 30, 2022, 
to January 05, 2023. 
 
You asked the Plan to pay for the inpatient hospital stay. You say that this 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 inpatient hospital 
stay provided on December 30, 2022, to January 05, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that rehabilitation is necessary due to the intensity and 
complexity of the enrollee's medical needs. The Plan denied your request. The Plan says that the IRF services 
requested do not meet the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found documentation shows the enrollee's condition is complex and fragile and complies with the various 
requirements for an IRF admission. There is also reason to expect the enrollee will participate in and benefit 
from IRF services. The requested IRF admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479, 88341, 88342 and 88360) provided on September 1, 2022.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
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. The medical records provided do not show the enrollee has recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. There are no lab results for previous testing using the same NGS test for the same primary diagnosis of cancer. Based on this information, all of the required Medicare criteria were not met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479, 88341, 88342 and 88360) provided on September 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a multi-axial rotation unit (L5986).
You asked the Plan to provide coverage for a multi-axial rotation unit (L5986). You say that at the time of the appeal, this prosthetic equipment was medically necessary. The Plan denied your request. The Plan says while the flexible foot was approved, the multi-axial rotation unit (L5986) could not be covered. Maximus overturned the Plans denial. The Plan requested a reopen and noted that L5986 does not represent a complete foot. It is part of a foot that must be paired with a complete foot based on functional classification. The Plan notes the medical records show the enrollee resides in a long-term care facility. The enrollee's physician does not state the multi-axial rotation unit is needed.
If this part is needed, this need must be corroborated by the actual medical records and not a provider with financial interest in the claim outcome. There must be clear documentation why this part is needed, which has not been provided.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare requires specific documentation be present in the medical records for certain prosthetic components. The records provided do not support a need for code L5986. Therefore, we decided that the Plan does not have to provide coverage for a multi-axial rotation unit (L5986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prescription glasses provided on November 15, 2022.
You asked the Plan to pay for this eyewear. You say that this eyewear should be covered by the Plan. The Plan denied your request. The Plan says this benefit was exhausted at the time of service. Maximus overturned the Plans denial for insufficient information in the case file to show eyewear was previously paid by the Plan. The Plan requested a reopen and provided information to show eyewear had been covered by the Plan on January 13, 2021.
The Plan is correct in this case. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers eyewear every 24 months. The Plan shows eyewear was purchased and paid for by the Plan on January 13, 2021.
You were not eligible for eyewear coverage under your contract until January 13, 2023. Therefore, we decided that the Plan does not have to pay for prescription glasses provided on November 15, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share charged for testing services provided on November 16, 2022.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct Medicare allowable. The records show you had a colonoscopy with poly removal. The Plan confirmed the Medicare allowed amount for this service is $1074.43. The $450 in network deductible applies leaving $624.44. Ten percent coinsurance once the deductible is met leaves a balance of $62.44 owed for this service.
The Plan is correct in this case. 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 meet the $450 deductible and then pay 10% coinsurance for outpatient hospital services. This was not a colonoscopy screening. You had a colonoscopy resulting in polyp removal. The deductible was not satisfied at the time of service and the coinsurance applies to any balance after the $450 is applied. 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 or reduce this cost share charged for testing services provided on November 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for all services billed for inpatient care provided to the from February 19, 2021, to April 15, 2021.
You asked the Plan to pay for this claim. The Plan denied your request. The Plan says this claim could not be paid as billed due to billing errors and inconsistency with the medical records. The Plan states the denied charges were due to items that were billed which are not allowed to be paid separately. Maximus overturned the Plans denial for missing documentation in the case file. The Plan requested a reopen and provided the required documentation. The Plan notes that once the itemized bill was received it was determined several items and services were identified as routine items and services inclusive to either room and board or included in the payment of a procedure, and therefore are not separately billable. The Plan upheld the denial of these routine items and services in the amount of $6,409.20. The Plan submitted the Itemized Bill Summary of denied charges. The Plan noted the Facility recently provided the itemized bill allowing the Plan to identify and validate the charges utilizing both the itemized bill and medical records. Ultimately the Plan upheld denied charges in the total amount of $6,409.20 and approved total charges in the amount of $306,251.00.
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.
In this case, review of the itemized bill and the itemized summary shows those codes that were denied by the Plan were done so because their payment is included in the payment of another code and therefore cannot be billed separately. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for services billed for inpatient care provided to the from February 19, 2021, to April 15, 2021, as originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical evaluation and lab services provided on a cruise ship on December 7, 2022.
You asked the Plan to pay for this service. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says your location at the time of service did not meet the criteria for payment. 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 according to Cruise Itinerary, on the date of the service, December 7, your location is not in the United States territorial waters. Also, according to the ship's physician, services provided were non-urgent and comprised of dizziness affecting walking.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all coverage information. Your contract with the Plan clearly says you have worldwide coverage for urgently needed services. The medical records show you were treated for dizziness outside of the US territories. Therefore, we decided that the Plan does not have to pay for the medical evaluation and lab services provided on a cruise ship on December 7, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, SNF admission was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria 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 is correct in this case. 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. The medical records provided show the enrollees needs were custodial in nature. The enrollee did not wish to be in the SNF and would not participate in therapy. Medicare coverage criteria were not met. Therefore, we decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the 6 additional home health visits for the enrollee.
You asked the Plan to provide coverage for 12 additional visits. The Plan denied your request. The Plan says 12 additional visits are not shown to be medically necessary. The Plan notes 6 of the 12 were approved. Maximus partially overturned the Plans denial, but basically made the same decision. The Plan requested a reopen for review correction.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. Our physician reviewer says that the enrollee was noted to have a strain of her iliopsoas muscle, and this can be addressed with 6 visits of home health physical therapy as well as a transition to a home exercise program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional visits have been met, which is the decision made by the Plan as well. Therefore, we decided that the Plan does not have to provide coverage for the 6 remaining visits out of the twelve requested.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve SNF care. You say that the enrollee has COVID and needs assistance to get out of bed. The Plan denied your request. The Plan says that a SNF admission is not medically necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF care. Our Medical Director states that the case file does not contain sufficient documentation supporting that it was medically necessary to provide skilled services on a daily basis in a skilled nursing facility setting. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.