Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pay forthe technical component of the chest x-ray (1 view) coded with 71045-TC. We decided that the Plan does not have to pay forthe remaining services. You asked the Plan to pay forthe technical component of the chest x-ray (1 view) coded with 71045-TC. You say that this should be paid since the provider had to return to take another x-ray.The Plan says that this claim is a duplicate and the services were already paid on a previous claim.We decided that the Planhas to pay forthe technical component of the chest x-ray (1 view) coded with 71045-TC.The Plan follows Medicare rules. Medicare rules say that duplicate claims should be denied as payment can only be made for services once.In this case, although it does appear that the plan made payment for most of these services on a prior claim, the remittance does not show that payment was ever made for code 71045-TC. Since no payment was made on the previous claim, denial of this line as duplicate is not valid.Therefore, we decided that the Plan has to pay forthe technical component of the chest x-ray (1 view) coded with 71045-TC.We also decided that the Plandoes not have to pay forthe remaining services.The Plan follows Medicare rules. Medicare rules say that duplicate claims should be denied as payment can only be made for services once.The remaining codes billed on this claim are shown to be reimbursed in a prior claim submission. As such, no additional payment can be made for these services.Therefore, we decided that the Plan does not have to pay forthe remaining 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: Imaging
Decision: Favorable

We decided the Plan does not have to pay forphysician services provided to the enrollee on May 12, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this service was previously paid to another provider of the same physician group. The case fileincludes the medical records, but they do not support that this was a separate and distinct service. The Plan says theNPI website shows both providers are of the same specialty group and work for the same practice. The case file includes the claim imagefor the appealed and referring claims that show that both providers belong to the same physician group. The Plan states the provider should have billed this service with modifier 59,which is used to distinguish separate and distinct service. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only oneservice may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met.Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on May 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered from June 10, 2020 to 
August 20, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy rendered from June 10, 2020 to August 20, 2020.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services provided on May 21, 2020. 
 
You asked the Plan to pay for the ultrasound services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are a duplicate. 
 
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 76642 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; limited. 
 
We find that CPT code 76642 is not supported in the medical record. Specifically, the documentation supports 
that this claim is an exact duplicate to a claim that was already received and processed by the plan. Based on 
this information, we decided that Medicare rules for coverage of the ultrasound services have not been met. 
Therefore, we decided that the Plan does not have to pay for the ultrasound services provided on May 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services provided to the enrollee on September 
17, 2020. 
 
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 this is not a Medicare-covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor's office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. 
Therefore, we decided that the Plan does not have to pay for transportation services provided to the enrollee on 
September 17, 2020.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for lumbar laminectomy 
and decompression for lumbar spinal stenosis. The enrollees medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided 
from September 4, 2020, to September 23, 2020. 
 
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you disagree 
with the denial because the therapy is crucial for your quality of life. The Plan denied your request. The Plan 
says the claims were processed correctly and you are being charged the correct amount. 
 
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 $10 
copayment for outpatient rehabilitation services provided in a specialist's office. 
 
You received outpatient rehabilitation services from September 4, 2020, to September 23, 2020, for a total of 3 
visits. Therefore, you are responsible to pay a $10 copayment per each visit. The total amount you owe is: $30.   
 
You have been asked to pay the total copayment amount of $30 for outpatient rehabilitation services. 
Outpatient rehabilitation services fall within the outpatient rehabilitation 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. Therefore, we decided that the Plan 
does not have to waive the copayments for outpatient rehabilitation services provided from September 4, 2020, 
to September 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammogram received on September 17, 2019. 
 
You asked the Plan to pay for the mammogram. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services received exceed the benefit limit. 
 
The Plan must follow Medicare rules. Medicare rules say that a screening mammogram is covered once every 
12 months.  
 
We looked at the file and Medicare rules. Review of the file shows that you received a mammogram on 
September 17, 2019. You previously received a mammogram on April 30, 2019. Twelve (12) months had not 
passed since your previous mammogram. Based on this information, we decided that Medicare rules for 
coverage of the mammogram have not been met. Therefore, we decided that the Plan does not have to pay for 
the mammogram received on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis provided on July 9, 2020. 
 
You asked the Plan to waive the copayment for arthrocentesis. You say that you were not billed for previous 
injections and you disagree with the charges. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 $200 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $200 copayment for arthrocentesis. Arthrocentesis falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 arthrocentesis provided on July 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that you are unable to care 
for yourself. The Plan denied your request. The Plan says that you have no acute symptoms that require 24-
hour care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It 
does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient 
level of care rather than a lower level of care beyond the dates in question as you do not have dangerousness to 
self or others and were compliant with your treatment. Our physician reviewer found that your condition does 
not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for occupational therapy services provided from May 12, 2020, to May 20, 
2020. 
 
You asked the Plan to pay for occupational therapy services. You say that this was billed correctly and the 
provider is enrolled in Medicare. The Plan denied your request. The Plan says that the PTAN for this provider 
cannot be verified. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The record shows that documentation confirming the providers PTAN and 
Medicare enrollment were submitted. The Plan has not provided information detailing why this information is 
insufficient or incorrect. Therefore, we decided that the Plan has to pay for occupational therapy services 
provided from May 12, 2020, to May 20, 2020.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the crown (D2740) and core build up (D2950) 
provided on August 25, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you were in an emergency when your 
crown came off while you were flossing. You say that your dental coverage reads, "the member's plan covers 
replacement of crowns that are at least 5 years old and cannot be approved. You also say that your crown is at 
least 20 years old. You also say that you have $2,000 for dental coverage and no previous claims this year. The 
Plan denied your request. The Plan says the crown is not listed as a covered service. The Plan says that core 
build up is not listed as a covered service either. The Plan also says that you did not contact them prior to the 
date of service to verify benefits and provider eligibility. 
 
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 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 reimburse you for 
the crown (D2740) and core build up (D2950) provided on August 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on September 2, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you did not request this service. 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 September 2, 2020. 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 services provided  on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to adjust the liability for the dental cleaning (D1110) provided on March 3, 2020. 
We also decided that the Plan does not have to adjust the cost share liability for the intraoral periapical first 
radiographic image (D0220), endodontic therapy (D3320), and the porcelain crown (D2752) provided from 
March 3, 2020, through June 17, 2020. 
 
You asked the Plan to adjust the cost share liability. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan says that the cost share liability has been applied correctly to the services 
provided. 
 
 
 
 
We decided that the Plan has to adjust the liability for the dental cleaning (D1110) provided on March 3, 
2020. This service was billed to the Plan for $88 by the out-of-network provider. The primary care dental 
insurance paid $40 of the amount billed, leaving a balance of $48, and the Plan paid $4 for this service. In this 
case, after primary payment, you stilled owed $48. As such, the Plan is obligated to pay the full amount of $44. 
Therefore, we decided that the Plan has to adjust your liability from $44 to $4.  
 
We also decided that the Plan does not have to adjust the cost share liability for the intraoral periapical 
first radiographic image (D0220), endodontic therapy (D3320), and the porcelain crown (D2752) 
provided from March 3, 2020, through June 17, 2020.  The out of network provider billed the Plan for the  
Intraoral periapical first radiographic covered image in the amount of $16, of which the Plan allowed amount 
of $14 was paid accordingly. Additionally, the provider billed the Plan in the amount of $2,106 for the 
endodontic therapy and the porcelain crown. The Plan allowed amount of $985 was paid at 50% as indicated in 
the Plan contract, which is $492.50. The primary dental insurance paid $388 for these services. Your total cost 
share liability for these services is $1,227.50. Therefore, we decided that the Plan does not have to adjust the 
cost share liability for the intraoral periapical first radiographic image (D0220), endodontic therapy (D3320), 
and the porcelain crown (D2752) provided from March 3, 2020, through June 17, 2020. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two additional intraoral periapical x-rays, resin-based 
composite, and amalgam provided on August 25, 2020, and September 1, 2020. 
 
You asked the Plan to pay for the intraoral periapical x-rays, resin-based composite, and amalgam. You say 
that prior to the services being rendered you were told that you would be fully covered. The Plan denied your 
request. The Plan says the benefits for these services had been satisfied and the frequency limitations had been 
exceeded. The Plan also says that the telephone calls with your dental office were reviewed, and accurate 
information was provided to the callers based upon the questions they posed. 
 
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 in excess of Medicare coverage, intraoral x-rays are limited to one 
procedure per calendar year, and restorations are limited to two procedures per calendar year. The record shows 
that you received a first intraoral periapical x-ray, amalgam, and resin-based composite on August 25, 2020, 
and your intraoral x-rays and restorations benefits had been exhausted. Therefore, we decided that the Plan 
does not have to pay for the two additional intraoral periapical x-rays, resin-based composite, and amalgam 
provided on August 25, 2020, and September 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthroscopy provided on July 24, 2020. 
 
You asked the Plan to waive the copayment for arthroscopy. You say that you were not aware that you would 
owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are 
being charged the correct amount. 
 
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 $200 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You have been asked to pay a $200 copayment for arthroscopy. Arthroscopy falls within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 arthroscopy provided on July 24, 2020.