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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee on January 21, 
2020 to January 23, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that that the member's condition and ongoing care 
needs did not meet medical necessity criteria for acute inpatient hospital level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. The record 
showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's 
necessary hospital care (including earlier emergency department and/or observation care) would span two 
midnights. Our physician reviewer found that the enrollee's condition met Medicare criteria for acute inpatient 
hospital 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided to the enrollee on January 21, 2020 to January 23, 
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 more for the extraction provided on June 2, 2020. 
 
You asked the Plan to pay more for the extraction. You say that the office called to make sure the code was 
fully covered. You say that money is tight and you hope the balance will be covered. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
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 Plan is only obligated to pay the 
allowed amount for the extraction. The remaining amount between the billed amount and allowed amount is 
your responsibility. Therefore, we decided that the Plan does not have to pay more for the extraction provided 
on June 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids (V5261) purchased July 29, 2019.You asked the Plan to pay forthe hearing aids. You say that the provider did not submit the prior authorization and you are requesting reconsideration.The Plan denied your request. The Plan says enrollee's must receive their hearing services from an in-network provider. Prior authorization is required before services are provided.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when a prior authorization has been received and when the services are provided by a participating provider. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay forthe hearing aids (V5261) purchased July 29, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on December 2, 2019. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on December 2, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on 
April 23, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is no itemized billing/shipping invoice to verify the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a proof of delivery to support medical necessity for the supplies provided in this 
case. There is no itemized billing/shipping invoice to verify the services billed. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on April 23, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the infectious agent detection respiratory panel rendered on February 
27, 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 that the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory panel is covered when specific 
criteria are met. 
 
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 pay for these services. Our reviewer says that the 
services were medically necessary. Our physician reviewer found the enrollee presented to the emergency 
department on February 27, 2020 with body aches and shortness of breath. An influenza swab was obtained, 
and the enrollee was diagnosed with Influenza A (H1N1). The documentation supports the testing for Influenza 
A and B, and RSV was performed in a healthcare setting that is equipped to care for and routinely does care for 
critically ill patients. The testing was reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pay for 
the infectious agent detection respiratory panel rendered on February 27, 2020.  
 
Local Coverage Article (LCA) A54769 referenced by the Plan does not contain coverage criteria, only billing 
criteria, and was not used in the MAXIMUS determination. 
 
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 laboratory testing provided on May 11, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the 
documentation submitted does not include a physician order, lab requisition, or medical records stating exactly 
which tests were to be performed and some of the tests billed do not match the sample type taken for testing. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order lab 
services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on May 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Oncotype DX breast DCIS test provided to the 
enrollee on October 11, 2019. 
 
You asked the Plan to pre-approve the test. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not a covered benefit under the plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 test. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support that the enrollee is a candidate for and is considering breast 
conserving surgery alone as well as breast conserving surgery combined with adjuvant radiation therapy, and 
that the test result would be used to determine treatment choice between surgery alone vs. surgery with 
radiation therapy. 
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Oncotype DX breast DCIS test provided to the enrollee on October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered chiropractic services provided. 
 
You asked the Plan to pay for the non-covered chiropractic services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
when provided 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 the non-covered chiropractic services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided from March 6, 2020 to 
August 6, 2020. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the charges because you 
have not paid for DME in years. 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 20% 
coinsurance for DME and related supplies.  
 
You received DME from March 6, 2020 to August 6, 2020 for a total of 5. The allowed amount per each visit is 
$128.50 and 20% of that is $25.70. The total amount you owe is: $25.70 (coinsurance) x 5 (DME services) = 
$128.50. 
 
You have been asked to pay the total coinsurance amount of $128.50 for DME. DME falls within the DME and 
related 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 coinsurance for DME provided from 
March 6, 2020 to August 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided by a participating 
hospital facility on June 15, 2020. 
 
You asked the Plan to waive the copayment for lab work. You say that you didn't know that if you went to an 
independent lab or the doctor's office you would have no copayment. The Plan denied your request. The Plan 
says the correct copayment has been 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 
copayment for outpatient diagnostic tests/lab services.  
 
You have been asked to pay a $30 copayment for lab work. Lab work falls within the outpatient diagnostic 
tests/lab 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 lab work provided 
by a participating hospital facility on June 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of a thigh fracture (27245) provided on 
November 19, 2019. 
 
You asked the Plan to pay for the treatment of a thigh fracture. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the actual date of service cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the treatment of a thigh fracture have not been met. Specifically, the record does not clearly 
indicate the actual date of service. We are unable to verify the billed date of service. Therefore, we decided that 
the Plan does not have to pay for the treatment of a thigh fracture (27245) provided on November 19, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99282) on April 
27, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were tested for 
COVID-19 and such testing should be covered in full. 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 $120 
copayment for emergency services.  
 
You have been asked to pay a $115.83 copayment for an emergency room visit. An emergency room visit falls 
within the "Emergency care" benefit category. This means that you have been asked to pay less than the full 
copayment 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 emergency room visit (99282) on April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enteral feeding supply kit, enteral formula, and foam 
dressing provided from December 1, 2019 to December 11, 2019. 
 
You asked the Plan to pay for the enteral feeding supply kit, enteral formula, and foam dressing. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
documentation does not include a physician order for the supplies provided. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the enteral feeding supply kit, enteral formula, and foam dressing 
provided from December 1, 2019 to December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis 
and resin-based composites provided on June 8, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis and resin-based 
composites. You say that you were given the wrong information the first time you called. You say that you 
were informed you would get some type of reimbursement because you were going out-of-network. The Plan 
denied your request. The Plan says out-of-network dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation, bitewing x-rays, prophylaxis and resin-based composites provided on June 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 6, 
2019, through December 7, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier emergency department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from December 6, 2019, through 
December 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on January 6, 2020. 
 
You asked the Plan to pay for the services provided. You say that the records support the billed code. The Plan 
denied your request. The Plan says the records do not support an additional 30 minutes of services. 
 
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 99292 is Critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, the documentation does not 
show that an additional 30 minutes of critical care was provided beyond the first 30-74 minutes of care. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the critical care services provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management (99496) provided on 
November 14, 2019. 
 
You asked the Plan to pay for the transitional care management. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says transitional care management 
services are performed after a patient's discharge and must be billed to the patient's home, a domiciliary center, 
rest home, nursing home or assisted living facility. 
 
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 99496 is Transitional Care Management Services with 
the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or 
caregiver within 2 business days of discharge Medical decision making of high complexity during the service 
period Face-to-face visit, within 7 calendar days of discharge  
 
We find that CPT code 99496 is not supported in the record. Specifically, this claim was billed with place of 
service code 31 for a Skilled Nursing Facility. Skilled Nursing Facilities do not apply for transitional care 
management services. Based on this information, we decided that Medicare rules for coverage of the 
transitional care management have not been met. Therefore, we decided that the Plan does not have to pay for 
transitional care management (99496) provided on November 14, 2019.