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

 
We decided that the Plan does not have to pay for the inpatient psychiatric admission provided on November 3, 2021. 
 
You asked the Plan to pay for the inpatient psychiatric admission provided on November 3, 2021. You say that 
the inpatient admission was appropriate and meets all medical necessity requirements. The Plan denied your 
request. The Plan says at the time of admission, the enrollee was not posing a risk of imminent harm to 
themself or others. The Plan also says that the enrollee did not require services that could only be provided in 
an acute inpatient setting. 
 
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 pay for the inpatient psychiatric admission provided 
on November 3, 2021. Our reviewer says that the enrollee does not meet the Medicare criteria for the inpatient 
psychiatric care. Our physician reviewer found it was not expected this enrollee would improve in a reasonable 
period of time as she did not have dangerousness to self or others and was not showing any auditory/visual 
hallucinations or any aggressive behaviors. Our reviewer also found that it did 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. 
 
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 inpatient psychiatric admission provided on November 3, 2021 have not 
been met. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric admission 
provided on November 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low vision lamp. 
 You asked the Plan to pre-approve these services. You say that  The Plan denied your request. The Plan says 
the services are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one routine eye exam per year and up to $200 for routine eyewear and low vision 
aids are excluded. 
 
We looked at the file and the Plan's rules. The Plans supplemental routine vision benefit does not cover low 
vision aids. Based on this information, we decided that the Plan's rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a low vision lamp.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (85060) provided on October 12, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the service should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on October 10, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the laboratory 
service (85060) provided on October 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for handling/conveyance of specimen for transfer from the office 
to a lab (99000) provided on September 29, 2021. 
 
You asked the Plan to pay for handling/conveyance of specimen for transfer. You say that this service was 
billed appropriately. The Plan denied your request. The Plan says payment for this service is always included in 
the payment for another 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. 
 
 We find that CPT code 99000 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99000 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of handling/conveyance of specimen for transfer have not been met. Therefore, we decided that the Plan does 
not have to pay for handling/conveyance of specimen for transfer from the office to a lab (99000) provided on 
September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291 and 99292) provided on 
November 11, 2021. 
 
You asked the Plan to pay for the critical care services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the critical care services (99291 and 
99292) provided on November 11, 2021, have been met. Specifically, the medical records submitted for this 
case are not for the date of service in question of November 11. Without relevant medical records, this claim 
cannot be reviewed for payment. Therefore, we decided that the Plan does not have to pay for the critical care 
services (99291 and 99292) provided on November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunohistochemistry or immunocytochemistry, per 
specimen; initial single antibody stain procedure (88342) provided May 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please see attached report to support 
payment for 88342. The Plan denied your request. The Plan says based on the records provided the requested 
service was not reasonable or necessary and does not meet the appropriate guidelines. 
 
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 88342 is immunohistochemistry or 
immunocytochemistry, per specimen; initial single antibody stain procedure. 
 
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 laboratory services. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our reviewer found the 
review indicates that the enrollee has a history of GERD. No clinical notes were provided to support the 
requested service. The review has determined that the medical records provided do not meet medical necessity 
requirements listed and the use of 88342 (5 units) is not supported by the medical records. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the immunohistochemistry or immunocytochemistry, per specimen; initial single 
antibody stain procedure (88342) provided May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Cologuard testing provided to the enrollee from September
1, 2021, to September 15, 2021.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and provided additional information. The
Plan stated that this screening is not a Medicare benefit. The recommended usage for Cologuard is every 3-
years. The Plan requested medical records on November 25, 2021, November 29, 202, December 1, 2021, and
December 3, 2021. These requests were not responded to.
The Plan is correct in this case. The Plan follows Medicare rules. The rules explicitly say that screening tests,
are not covered. Insufficient medical records were submitted with the claim to show this test was not a
screening but ordered for a specific diagnosis.
Therefore, we decided that the Plan does not have to pay for Cologuard testing provided to the enrollee from
September 1, 2021, to September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the core buildup, including any pins when required 
(D2950) and crown (D2750) provided on December 4, 2021. 
 
You asked the Plan to pay more for the core buildup and crown. You say that you thought this service would be 
covered when you signed up for the dental plan. The Plan denied your request. The Plan says benefits have 
been paid on the least costly method of treatment, and you will be responsible for the remaining balance. The 
Plan also says that when there are multiple, clinically acceptable treatment options, the Plan will pay for the 
least expensive treatment option. 
 
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, you are responsible for a 50% 
coinsurance for Class 3 Major Services, including crown and core buildup. The contract also says that if a 
method of treatment is more costly than is customarily provided, benefits will be paid on the least costly 
method of treatment, and you will be responsible for the remaining balance. The record shows that you 
received a porcelain fused to high noble metal crown (D2750), and the Plan charged you for the lesser costly 
method of a porcelain fused to predominantly base metal crown (D2751). You are responsible for the 50% 
coinsurance for the porcelain fused to predominantly base metal crown (D2751) and the difference between the 
allowed amount for the porcelain fused to high noble metal crown (D2750) and the allowed amount for the 
porcelain fused to predominantly base metal crown (D2751). Therefore, we decided that the Plan does not have 
to pay more for the core buildup, including any pins when required (D2950) and crown (D2750) provided on 
December 4, 2021.  
 
Your complaint about your disappointment in the Plans coverage and believing it may be fraud 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional personal care assistant (PCA) services. 
 
You asked the Plan to pre-approve these services. You say that you are getting sicker and fragile due to 
syncope and heart issues. The Plan denied your request. The Plan says the services are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered.  
 
We looked at the file and Medicare rules. The services at issue are custodial in nature. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. These services 
are covered by the Medicaid portion of your Plan. Therefore, we decided that the Plan does not have to pre-
approve additional personal care assistant (PCA) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional occupational therapy home health visit 
(G0152). 
 You asked the Plan to pre-approve 6 additional occupational therapy home health visit. You say that home 
health occupational therapy continues to be medically necessary for your condition. The Plan denied your 
request. The Plan says the criteria for coverage for home health services beyond what has been approved have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 6 additional occupational therapy home 
health visit. Our reviewer says that the requested occupational therapy is not medically reasonable and 
necessary. Our physician reviewer found the enrollee is a 64-year-old female with a history of chronic 
obstructive pulmonary disease, chronic kidney disease and osteoarthritis. Based on the documentation 
provided, the enrollee does not have documented, home health occupational therapy needs. The enrollee is 
functioning at a level commiserate with a lower level of care (i.e. home exercise program, outpatient therapy, 
lay person assistance).  As such, the requested services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 additional occupational therapy home health visit have not been met. 
Therefore, we decided that the Plan does not have to pre-approve 6 additional occupational therapy home 
health visit (G0152).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay additionally for the dental services (D7953, D9120, D6245, and 
D6740) provided on December 7, 2021. 
 
You asked the Plan to pay additionally for dental codes D7953, D9120, D6245, and D6740. You say that you 
would like the Plan to reconsider your request. The Plan denied your request. The Plan says dental codes 
D7953 and D9120 are not covered under the Plan's supplemental dental benefit. The Plan's contract says you 
have a $1500 maximum that applies towards covered dental services. The Plan says you reached this $1500 
maximum benefit during the processing of this claim making the payment for dental code D6740 your 
responsibility and the difference of payment for dental code D6245 also your responsibility. 
 
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, dental codes D7953 and D9120 are not 
among those covered under this benefit. The Plan's contract says you have a $1500 maximum that applies 
towards covered dental services. The file shows you reached this $1500 maximum benefit during the 
processing of this claim making the payment for dental code D6740 your responsibility and the difference of 
payment for dental code D6245 also your responsibility. Therefore, we decided that the Plan does not have to 
pay additionally for the dental services (D7953, D9120, D6245, and D6740) provided on December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206 and 81292) provided on July 
26, 2021. 
 
You asked the Plan to pay for codes 81206 and 81292. 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 as 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. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206 and 81292) provided on July 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional home health physical therapy visits. 
 
You asked the Plan to pre-approve 6 additional home health physical therapy visits. You say that the 6 
additional home health physical therapy visits are medically necessary. The Plan denied your request. The Plan 
says the 6 additional home health physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 6 additional home health physical 
therapy visits. Our reviewer says that the 6 additional home health physical therapy visits are not medically 
necessary. Our physician reviewer found based on the documentation provided, the enrollee does not have 
documented, home health (HH) physical therapy (PT) needs. The enrollee is functioning at a level commiserate 
with a lower level of care.  As such, the requested, 6 additional HH PT services are not medically necessary or 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 additional home health physical therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 6 additional home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing panel (81404, 81479). 
 
You asked the Plan to pay for the cardiovascular genetic testing panel. You say that you would like this claim 
reprocessed based on medical necessity. The Plan denied your request. The Plan says the Plan is arguing that 
the requested cardiovascular genetic testing panel is never covered by Medicare. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is subject to the criteria listed in the 
Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the cardiovascular genetic testing panel. 
Our reviewer says that the provided cardiovascular testing was not medically reasonable and necessary. Our 
physician reviewer found that issue is whether the requested genetic testing was medically appropriate and 
necessary. The test is described as a genetic based cardiovascular risk factor screening test in which multiple 
genes are assessed using genomic DNA extracted from patient sampling. It assesses the presence of pathogenic 
or likely pathogenic variants in genes known to be associated with increased cardiac risk. It is not a diagnostic 
test. There is no evidence to support its role in this patient clinical management. In summary, the requested 
testing is not considered 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 cardiovascular genetic testing panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the cardiovascular genetic testing panel (81404, 81479).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206, 81235, 81321) provided 
on October 9, 2020. You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed based no medical necessity. The Plan denied your request. The Plan says this has not been billed correctly 
based on Medicare coding regulations. 
 
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 looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81206, 81235, 81321) provided on October 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cleaning (D1110), the periodic oral evaluation (D0120), 
the pin retention (D2951), the amalgam (D2160), and the panoramic x-ray (D0330) provided by an out-of-
network provider from February 18, 2021, to October 18, 2021. 
 
You asked the Plan to pay for the cleaning (D1110), the periodic oral evaluation (D0120), the pin retention 
(D2951), the amalgam (D2160), and the panoramic x-ray (D0330). You say that you did not know you had 
dental benefits. You say you have been seeing your dentist for over 30 years and do not want to change 
dentists. The Plan denied your request. The Plan says you have been asked to pay the correct cost sharing 
amount for the cleanings and the evaluations. The remaining 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 Plan's coverage rules apply 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 50% coinsurance for out-of-
network cleanings (D1110) and periodic oral evaluations (D0120). 
 
You have been asked to pay $27 which is 50% of the allowed amount for the cleanings on April 12, 2021, and 
October 18, 2021. The allowed amount is $54. ($54 x 50% = $27).  
 
You have also been asked to pay $13.50 which is 50% of the allowed amount for the periodic oral evaluations 
on April 12, 2021, and October 18, 2021. The allowed amount is $27. ($27 x 50% = $13.50). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the pin retention (D2951), the 
amalgam (D2160), and the panoramic x-ray (D0330) are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the cleaning (D1110), the periodic oral evaluation 
(D0120), the pin retention (D2951), the amalgam (D2160), and the panoramic x-ray (D0330) provided by an 
out-of-network provider from February 18, 2021, to October 18, 2021.