Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit (99203) and an x-ray (72100) 
provided on June 18, 2019. 
 
You asked the Plan to pay for a chiropractic office visit and an x-ray. You say that this doctor was able to help 
you walk. The Plan denied your request. The Plan says these services are not covered when performed by a 
chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a chiropractic office visit (99203) and an x-ray (72100) provided on June 18, 
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation, bitewing x-rays, and 
prophylaxis provided on September 17, 2020 by an OON provider. 
 
You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that 
you have been going to this provider for fifteen years, and did not realize they are OON. The Plan denied your 
request. The Plan says the total $164.00 amount applied correctly as your liability. The Plan also says that cost 
sharing is a contractual obligation under the Plan and cannot be waived. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more 
for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on September 17, 2020 by an OON 
provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to adjust the cost sharing for the ocular membrane treatment provided on 
September 3, 2020. 
 
You asked the Plan to adjust the cost sharing for the ocular membrane treatment. You say that you were told 
that this service would have a $50 copayment. You do not feel you owe $383 because of the misinformation 
you were given by the Plan. The Plan denied your request. The Plan says that the office visit charge was 
correctly denied as included in payment for the surgical service. 
 
The Plan must follow Medicare rules. Medicare rules say that health plans must clearly disclose cost sharing 
information to enrollees. Your contract clearly says that there is a $50 copayment for Medicare-covered vision 
services.  
 
The treatment you received was a Medicare-covered vision service. The Plan incorrectly applied coinsurance to 
this service. You cannot be asked to pay more than a $50 copayment for this service. Therefore, we decided 
that the Plan has to adjust the cost sharing for the ocular membrane treatment provided on September 3, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the biopsy of the esophagus, stomach, 
and/or upper small bowel using an endoscope (43239) provided on July 15, 2020. 
 
You asked the Plan to waive the copayment for the biopsy of the esophagus, stomach, and/or upper small 
bowel using an endoscope. You say that you would like this copayment waived. The Plan denied your request. 
The Plan says this copayment has processed correctly 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 pay a $350 
copayment for outpatient hospital services.  
 
You have been asked to pay a $350 copayment for the biopsy of the esophagus, stomach, and/or upper small 
bowel using an endoscope. The service provided falls within the outpatient hospital 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 the biopsy of the esophagus, stomach, and/or upper small 
bowel using an endoscope (43239) provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test provided. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that you were advised by the Plan that 
this provider is in-network. The Plan denied your request. The Plan says the adjunctive pre-diagnostic test is 
not covered by your benefits. The Plan also says that your bitewing x-rays benefits are limited to only once per 
calendar year, and this procedure had already been performed. 
 
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 adjunctive pre-diagnostic test is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
adjunctive pre-diagnostic test provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation 
correction and anatomical localization imaging; skull base to mid-thigh (CPT Code 78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan is necessary. The Plan denied your 
request. The Plan says the scan is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET scan. Our physician reviewer 
found PET scans are not indicated for surveillance after completion of initial therapy after response has been 
documented. This enrollee completed definitive therapy in 2017 as has remained with no evidence of disease 
and has no signs or symptoms of recurrence. A PET scan is not reasonable or medically 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization 
imaging; skull base to mid-thigh (CPT Code 78815).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care received on August 
5 to August 10, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not be 
responsible for this bill. The Plan denied your request. The Plan says the correct copayment 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 $315 
copayment for each day of days 1-6 of each Medicare-covered hospital stay.  
 
You have been asked to pay $1,575, or a $315 copayment for each day of a 5-day hospital stay for inpatient 
hospital care. 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 inpatient hospital care received on August 5 
to August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay forphysician services provided to the enrollee from April 29, 2020, to June 10, 2020.You asked the Plan to pay these services. You say that you are eligible to accept Medicare payment as an out of network provider and these services should be covered by the Plan. The Plan denied your request. The Plan says that you are excluded or debarred from participation in State and Federalhealthcare programs. Maximus upheld the Plans denial. After additional review of several cases from your office, we reopened the appeal. 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. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services were met. The Plan did not provide documentation to show that you are excluded from receiving Medicare reimbursement. Maximus performed a search of the List of Excluded Individuals and/or Entities from the Office of Inspector General and did not find that you were on this list. Without specific documentation from the Plan showing that you were excluded to receive Medicare reimbursement at the time the services were provided, the denial cannot be substantiatedTherefore, we decided that the Plan has to pay forphysician services provided to the enrollee from April 29, 2020, to June 10, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay forphysician services provided to the enrollee from June 25, 2020 to July 7, 2020.You asked the Plan to pay these services. You say that you are eligible to accept Medicare payment as an out of network provider and these services should be covered by the Plan. The Plan denied your request. The Plan says that you are excluded or debarred from participation in State and Federal healthcare programs. We upheld the Plans denial. After additional review of several cases from your office, we reopened the appeal. 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. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services were met. The Plan did not provide documentation to show that you are excluded from receiving Medicare reimbursement. We performed a search of the List of Excluded Individuals and/or Entities from the Office of Inspector General and did not find that you were on this list. Without specific documentation from the Plan showing that you were excluded to receive Medicare reimbursement at the time the services were provided, the denial cannot be substantiated. Therefore, we decided that the Plan has to pay forphysician services provided to the enrollee from June 25, 2020 to July 7, 2020.If the Plandoes 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 doesnot 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee's medical condition has stabilized. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that the enrollee has been in the hospital for Covid-19. The enrollee is receiving appropriate 
care at the present acute care hospital. The enrollee does not require services at the LTACH that are not 
available at the acute care hospital where she is currently receiving care. There are no services available at the 
LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultraviolet light therapy (96900) provided 
from January 2, 2020 to October 13, 2020. 
 
You asked the Plan to waive the copayment for ultraviolet light therapy. You say that you did not expect to 
have a copay for these services because you did not have one in 2019. The Plan denied your request. The Plan 
says specialist physician services have a $40 copayment. 
 
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 $40 
copayment for Physician/Practitioner services.  
 
You have been asked to pay a $19 copayment for each session of ultraviolet light therapy. Ultraviolet light 
therapy falls within the Physician/Practitioner services benefit category and is subject to a $40 copayment per 
service. This means that you have been asked to pay the correct amount based on your contract with the Plan 
for 2020. 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 ultraviolet light therapy (96900) 
provided from January 2, 2020 to October 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from October 17, 2018 to 
December 11, 2018. 
 
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 claims were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that a treatment authorization code is required for 
home health claims. 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with a required 
treatment authorization code. 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 home health 
services rendered from October 17, 2018 to December 11, 2018.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the open treatment of radiocarpal or intercarpal dislocation 
(25670) provided on May 31, 2019. 
 
You asked the Plan to pay for the open treatment of radiocarpal or intercarpal dislocation. You say that you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 
documentation submitted does not support the service billed. 
 
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 25670 is open treatment of radiocarpal or intercarpal 
dislocation, one or more bones. 
 
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 the open treatment of radiocarpal or intercarpal dislocation. 
Our reviewer says that CPT code 25670 does not meet criteria for billing or reimbursement consideration. Our 
reviewer found the medical records provided do not include sufficient documentation to validate that an open 
treatment of radiocarpal or intercarpal dislocation, one or more bones was performed on May 31, 2019. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the open treatment of radiocarpal or intercarpal dislocation have not been met. 
Therefore, we decided that the Plan does not have to pay for the open treatment of radiocarpal or intercarpal 
dislocation (25670) provided on May 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on October 2, 2020. 
 
You asked the Plan to pay for the scaling. You say that you cannot afford to pay for this service. The Plan 
denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
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 pay for the 
scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on October 2, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services (92014) provided on August 
28, 2020. 
 
You asked the Plan to pay for the ophthalmological services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the provider billed H35.313 and 
that is an incomplete diagnosis. 
 
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 code 92014 is not supported in the record. Specifically, per the ICD-10, all diagnosis codes 
under H35.31 require a 7th character to designate the stage of the disease. The diagnosis code billed is 
incomplete. Based on this information, we decided that Medicare rules for coverage of the ophthalmological 
services have not been met. Therefore, we decided that the Plan does not have to pay for the ophthalmological 
services (92014) provided on August 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045) provided on March 25, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says CPT code 71045 is not supported as being performed 
on the billed date of service. 
 
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 the 
chest x-ray has a bundled relationship with code 32550 and cannot be paid as billed. This code cannot be paid 
as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, 
we decided that the Plan does not have to pay for the chest x-ray (71045) provided on March 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the charges 
because the labs were taken as part of your wellness exam. 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 $20 
copayment for lab services provided in a freestanding laboratory.  
 
You received laboratory services, at a freestanding laboratory. Laboratory services are 
not included in annual wellness exams. Therefore, you are responsible to pay the $20 copayment.  
 
You have been asked to pay a $20 copayment for laboratory services. Laboratory services fall 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 for laboratory services provided.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that you are status-post prostate surgery, and had a fall at home. The Plan denied your request. The Plan says rehab needs and medical needs can be met at a lower level of care with skilled intermittent therapy and nursing in a community setting.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready for discharge from the hospital.  You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility.

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).