Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
April 12, 2020, to April 16, 2020. 
 
You asked the Plan to waive the copayment for inpatient stay. You say that you were told by the provider that 
you were only going to be billed $300 for this stay. The Plan denied your request. The Plan says the copayment 
amount you are being charged is correct. 
 
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 $150 
copayment per day for days 1 to 7 and $0 copayment per day for days 8 to 90 for inpatient stay. This inpatient 
stay lasted 4 days, resulting in a copayment obligation of $600. 
 
You have been asked to pay $150 copayment per day for days 1 to 7 and $0 copayment per day for days 8 to 90 
for inpatient stay. Inpatient stay 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 waive the copayment for an inpatient hospital stay provided from April 12, 2020, to April 16, 
2020.  
 
Your complaint regarding receiving inaccurate information about your cost-share responsibility for this stay is 
considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. 
Please contact the Plan for more information about your grievance.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunohistochemistry or immunocytochemistry services 
coded 88342 and 88341 provided on March 27, 2020. 
 
You asked the Plan to pay for the immunohistochemistry or immunocytochemistry 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 not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 88342 and 88341 are not supported in the medical record. Specifically, 
Immunocytochemistry (e.g., CPT codes 88342, 88341, 88344, 88360, 88361) and flow cytometry  (e.g., CPT 
codes 88184-88189) should not in general be reported for the same or similar 
specimens. The diagnosis should be established using one of these methods. The physician may report both 
CPT codes if both methods are required because the initial method does not explain all the light microscopic 
findings. The physician may report both methods utilizing modifier 59 and document the need for both 
methods in the medical record. If the abnormal cells in two or more specimens are morphologically similar and 
testing on one specimen by one method (CPT codes 88184, 88187, 88188, 88189, 88342, 88341, and 88344) 
establishes the diagnosis, the same or other method shall not be reported on the same or similar specimen. 
Similar specimens would include, but are not limited to: 
(1) blood and bone marrow; 
(2) bone marrow aspiration and bone marrow biopsy; 
(3) two separate lymph nodes; or 
(4) lymph node and other tissue with lymphoid infiltrate). 
Since the primary code was denied, the add-on code is also not covered. Based on this information, we decided 
that Medicare rules for coverage of the immunohistochemistry or immunocytochemistry services have not been 
met. Therefore, we decided that the Plan does not have to pay for the immunohistochemistry or 
immunocytochemistry services coded 88342 and 88341 provided on March 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on June 11, 2020. 
 
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a drug test provided on June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing care (99306, 99308) 
provided November 13, 2019 to November 16, 2019. 
 
You asked the Plan to waive the copayment for the skilled nursing care. You say that the copayment should be 
waived. The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
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 30% 
coinsurance for Out-of-network Skilled Nursing Facility Services.  
 
You have been asked to pay a 30% coinsurance for the skilled nursing care. The skilled nursing care falls 
within the Out-of-network Skilled Nursing Facility 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 copayment for skilled nursing care (99306, 99308) provided November 13, 2019 to November 16, 
2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided to the enrollee on October 11, 2018 
and billed under codes 80307 and G0481. 
 
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 insufficient medical records and physician documentation were submitted to support the 
services billed. 
 
The Plan follows Medicare rules. Medicare rules say that providers must produce medical records showing 
why the lab services provided were medically necessary. In this case, there were insufficient records provided 
to show the results of this testing would be used to determine a diagnosis or determine a treatment strategy for 
disease or illness present in the enrollee at the time of service.  
 
 
 
 
 
 
This testing is not covered for screening purposes. Medicare coverage criteria are not met. Therefore, we 
decided that the Plan does not have to pay for drug testing provided to the enrollee on October 11, 2018 and 
billed under codes 80307 and G0481.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services billed with CPT code 99291. 
 
You asked the Plan to pay for the critical care services. You say that the medical records provided support the 
services in dispute. The Plan denied your request. The Plan says the services billed were not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that critical care is not a service that is paid on a 
?shift? basis or a ?per day? basis. Critical care services are paid on a time-based service provided on an hourly 
or fraction of an hour basis. For this reason, the documentation provided by the physician must include the 
amount of time in hours and minutes that is spent on providing critical care service. 
 
 
 
We looked at the file and Medicare rules. The records provided reference critical care services provided on. 
However, the documentation does not show a total time of 30-74 minutes spent delivering 
critical care to the enrollee, which is the date of service billed. Based on this 
information, we decided that Medicare rules for coverage of the critical care services have not been met. 
Therefore, we decided that the Plan does not have to pay for critical care services billed with CPT code 99291.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Caris MI tumor profile services provided on March 14,
2020 by an out of network (OON) provider.
You asked the Plan to pay for the Caris MI tumor profile services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered
benefit.
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 has network providers
available who can provide 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 Caris MI tumor profile services provided on
March 14, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on April 6, 2020.
You asked the Plan to pay for the drug testing. You say that this should be paid due to medical necessity. The Plan denied your request. The Plan says there is no valid order for the rendered services.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating provider. In this case, the laboratory requisition form does not clearly indicate the intent for a presumptive screen nor does it indicate that confirmation should be done solely on the prescribed drugs. It does not provide any information on the intent for which drug classes should be tested. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on April 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee out of network on 
October 28, 2019. 
 
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 the enrollee did not have prior authorization for out of network care. 
 
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 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. 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 lab services provided to the 
enrollee out of network on October 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fracture treatment (25605) provided on June 18, 2019. 
 
You asked the Plan to pay for fracture treatment. You say that this is supported. The Plan denied your request. 
The Plan says this code is not documented. 
 
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 25605 is closed treatment of distal radial fracture (eg, 
Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when 
performed; with manipulation. 
 
We find that CPT code 25605 is not supported in the medical record. Specifically, the submitted medical 
records do not include clear and legible documentation of this procedure. Based on this information, we 
decided that Medicare rules for coverage of fracture treatment have not been met. Therefore, we decided that 
the Plan does not have to pay for fracture treatment (25605) provided on June 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a heart stress test (93351) and a Perflutren 
injection (Q9957) received on March 1, 2018. 
 
You asked the Plan to waive the coinsurance for a heart stress test and a Perflutren injection. You say that you 
were told by the provider's office that you would have no copayments for these services. The Plan denied your 
request. The Plan says the correct coinsurance was applied. 
 
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 20% 
coinsurance for Medicare-covered non-radiological diagnostic services and for each Medicare-covered Part B 
drug.  
 
You have been asked to pay a total of $196.20, or 20% coinsurance of the Plan-allowed amount of $981, for a 
heart stress test and a Perflutren injection. A heart stress test falls within the "Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies" benefit category. A Perflutren injection falls within the "Medicare Part B 
Prescription Drugs" 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 coinsurance for a heart stress test 
(93351) and a Perflutren injection (Q9957) received on March 1, 2018.  
 
Your complaint about receiving erroneous or misleading information about cost-sharing from the provider?s 
office is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 18, 
2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the nursing home is 
responsible to obtain authorization. The Plan denied your request. The Plan says non-emergent, non-urgent 
services with out-of-network providers require prior authorization.  
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on November 18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound examination provided on March 24, 2020.You asked the Plan to waive the copayment forultrasound. You say that no payment was made by the Plan for this claim.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $155 copayment for ultrasound exam at a freestanding radiology facility. You have been asked to pay the allowed amount of $145.03, which is less than the $155 copayment for ultrasound. Ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 foran ultrasound examination provided on March 24, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on May 23, 2019.
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 procedure codes 95941 and 95813 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95813 is electroencephalogram (EEG) extended monitoring; 61-119 minutes. We find that CPT code 95813 is not supported in the medical record. Specifically, the technical report does not include documentation of an EEG with extended monitoring for 61-119 minutes. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. The provider billed code 95941. This code has a status indicator of I and is not valid for Medicare purposes. 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 pay for the testing services rendered on May 23, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 20, 2020 by an out 
of network (OON) provider. 
 
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 were rendered by a non-plan provider without prior authorization. 
 
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 has network providers 
available who can provide 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 laboratory services provided on July 20, 2020 
by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the thirty (30) minutes of psychotherapy (90832) and
Federally qualified health center visit (G0470) provided on June 21, 2019 by an out of network (OON)
provider.
You asked the Plan to pay for psychotherapy and health center visit. You say that the services rendered were
medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for nonemergent
services rendered by an out-of-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 has network providers
available who can provide 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 thirty (30) minutes of psychotherapy (90832)
and Federally qualified health center visit (G0470) provided on June 21, 2019 by an out of network (OON)
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99328) provided on April 
15, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary visit. You say that prior authorization is not required for 
telemedicine. The Plan denied your request. The Plan says prior authorization must be obtained for non-
emergent services rendered by an out-of-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 has network providers 
available who can provide 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 domiciliary or rest home visit (99328) 
provided on April 15, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the relaxation gas (D9230) provided on March 3, 2020. 
 
You asked the Plan to pay for the dental service. You say that you needed the relaxation gas due to previous 
trauma. The Plan denied your request. The Plan says the relaxation gas was not medically necessary for the 
services that were provided. 
 
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 
covered under this benefit if they are not considered medically necessary for the diagnosis, treatment or care 
provided. Therefore, we decided that the Plan does not have to pay for the relaxation gas (D9230) provided on 
March 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the left knee (73564-LT) provided on October 30, 
2019. 
 
You asked the Plan to pay for an x-ray of the left knee. You say that this should be covered. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the billing of this claim is not supported. Specifically, CPT 73564 was billed with the LT 
modifier, indicating it was performed on the left side, but it was billed with the diagnosis S80.01XA, which 
indicates a contusion of right knee. Based on this information, we decided that Medicare rules for coverage of 
an x-ray of the left knee have not been met. Therefore, we decided that the Plan does not have to pay for an x-
ray of the left knee (73564-LT) provided on October 30, 2019.