Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a bone growth stimulator provided on 
December 29, 2021. 
 
You asked the Plan to waive the coinsurance for the stimulator. You say that the device was too big and you 
could not use it. 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 a 20% 
coinsurance for durable medical equipment (DME).  
 
You have been asked to pay $570.09, which is 20% of the allowed amount for the stimulator ($2,850.43 
allowed amount x 20% coinsurance = $570.09). The stimulator falls within the Durable Medical Equipment 
(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 a bone 
growth stimulator provided on December 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70551 billed for date of service February 26, 
2022. 
 
You asked the Plan to pay for procedure code 70551. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70551 is bundled into payment for 
code 70552. 
 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 70551 
is a column II code to column I code 70552. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70551 billed for date of service February 26, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 64999 billed for date of service January 4, 2022. 
 
You asked the Plan to pay for procedure code 64999. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says that because this is an unlisted code, medical 
records are required to determine if the service is covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole denial is based on the fact that medical records were 
needed to determine if this code was payable. You provided medical records with your appeal request.  It does 
not appear as though the Plan made any attempt to review these records to make this determination.  The 
burden is on the Plan to justify its denial.  Because the Plan's denial was predicated solely on a lack of medical 
records (which they now have), the Plan's denial cannot be substantiated. Therefore, we decided that the Plan 
has to pay for procedure code 64999 billed for date of service January 4, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for pre-admission and inpatient services provided to the enrollee
from November 29, 2021, to November 30, 2021, and December 2, 2021, to January 11, 2022.
You asked the Plan to pay for the pre-admission services and inpatient services provided to the enrollee. You
say that these services should be paid. The Plan denied your request. The Plan says the enrollee was not a
member of the Plan during the hospital stay. Because the pre-admission services would be included in the
global diagnosis related group (DRG) payment, they cannot be paid separately, and the enrollee was not a
member of the Plan when the inpatient stay began on December 2, 2021. Maximus partially overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing guidelines.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that when a beneficiary is a
member of a plan for only a portion of an inpatient hospital stay, the payer at the time of
the patient's admission to inpatient care is responsible for the cost of the entire stay.
The rules also say that diagnostic services (including clinical diagnostic laboratory tests) and other
preadmission services provided to a beneficiary by the admitting hospital within 3 days prior to and including
the date of the beneficiary's admission are included in the inpatient payment and cannot be billed separately.
In this case, the payment for the pre-admission services provided to the enrollee from November 29, 2021, to
November 30, 2021, would have been included in the claim submitted by the facility for the inpatient stay. The
enrollee disenrolled from the Plan on December 1, 2021. The enrollee was admitted as an inpatient on
December 2, 2021. As the enrollee was not a member of the Plan on the day of the admission, the preadmission
services cannot be paid separately by the Plan. As the enrollee disenrolled the day prior to
admission, the Plan also is not responsible for payment of the inpatient stay. Therefore, we decided that the
Plan does not have to pay for pre-admission and inpatient services provided to the enrollee from November 29,
2021, to November 30, 2021 and December 2, 2021 to January 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
December 25, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that since the enrollee 
was admitted to the hospital there should be no charge. The Plan denied your request. The Plan says the 
enrollee has been charged the correct cost sharing 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for each separate ambulance service. This copayment is not waived even if you are 
admitted to the hospital as an inpatient immediately following the ambulance transport.  
 
The enrollee has been asked to pay a $250 copayment for the ambulance transportation. The ambulance 
transportation falls within the Ambulance Services benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for ambulance transportation provided on December 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided to the enrollee on January 
11, 2022. 
 
You asked the Plan to pay for the services. You say that you did not know that this was not covered in an 
office. The Plan denied your request. The Plan says this is a non-covered charge. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the services. 
Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on 
January 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 14, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not billed in this case to bypass the edit. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on January 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on December 
28, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the Explanation of Benefits (EOB) from the primary carrier has not been received yet. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has The plan has 
directed the ambulance provider to submit a claim to the primary carrier for processing.. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for 
these services. Therefore, we decided that the Plan does not have to pay for ambulance services provided to the 
enrollee on December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (code D4341) provided 
on January 24, 2022, to January 25, 2022. 
 
You asked the Plan to pay for the scaling and planing. You say that you were told that this service was covered. 
The Plan denied your request. The Plan says this service is not covered under your supplemental dental 
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, 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 
periodontal scaling and root planing (code D4341) provided on January 24, 2022, to January 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service January 24, 
2022. 
 You asked the Plan to pay for procedure code 76942. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 76942 is bundled into 
payment for code 78226. 
 
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 76942 
is a column II code to column I code 78226. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76942 billed for date of service January 24, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 86850, 86900, and 86901 billed for date of 
service December 27, 2021. 
 
You asked the Plan to pay for procedure codes 86850, 86900, and 86901. You say that this claim was 
underpaid. The Plan denied your request. The Plan says no additional payment is made for these codes. 
 
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 86850, 86900, and 86901 has a status indicator of N in the Outpatient Prospective 
Payment System. This means that CPT codes 86850, 86900, and 86901 are not separately payable. Based on 
this information, we decided that Medicare rules for coverage of procedure codes 86850, 86900, and 86901 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 86850, 86900, 
and 86901 billed for date of service December 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64447 and 99135 billed for date of service 
January 3, 2022. 
 
You asked the Plan to pay for procedure codes 64447 and 99135. You say that the facility where these services 
occurred was in-network, so these services should be paid at the Medicare-allowed rate. The Plan denied your 
request. The Plan says payment for code 64447 is bundled into payment for code 01402.  The Plan also says 
that code 99135 is never separately payable. 
 
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 64447 
is a column II code to column I code 01402. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met for this code.  In 
regards to code 99135, this code has a status indicator of B on the Medicare Physician Fee Schedule. This 
means that this code is not separately payable. Therefore, we decided that the Plan does not have to pay for 
procedure codes 64447 and 99135 billed for date of service January 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy performed on February 8, 
2022. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that you were informed that the 
procedure would be covered in full. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing 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 $375 
copayment per visit for surgery or other services at an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay a $375 copayment for the endoscopy. The endoscopy falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an endoscopy performed on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99135 billed for date of service 
December 23, 2021. 
 
You asked the Plan to pay for procedure code 99100 and 99135. You did not provide a specific argument with 
your appeal request. The Plan denied your request. The Plan says no separate payment is made for these codes. 
 
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 99100 and 99135 have a status indicator of B on the Physician Fee Schedule. This 
means that CPT codes 99100 and 99135 are not separately payable. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99100 and 99135 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 99100 and 99135 billed for date of service December 23, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve a complete upper denture and a partial lower denture. You say that you 
refused your original dentures because they looked like baby teeth. The provider proceeded with another 
impression and the dentures still did not fit you well. The dentures were scratching and causing your gums to 
bleed. You would like your dental benefits reinstated so you can have dental work done with a different 
provider. The Plan denied your request. The Plan says complete and partial dentures are covered once every 
five years. 
 
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. The Plan covers a complete 
upper denture and a partial lower denture once every five years.  
 
 We looked at the file and Medicare rules. The records show that you received a complete upper denture and a 
partial lower denture on December 21, 2021, therefore, you have exhausted your maximum benefit for these 
services. Based on this information, we decided that the Plan's rules for coverage of a complete upper denture 
and a partial lower denture have not been met. Therefore, we decided that the Plan does not have to pre-
approve a complete upper denture (D5110) and a partial lower denture (D5214).  
 
Your complaint about the provider who provided dentures for you in December 2021 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 the initial observation care (99220) provided on December 8, 2021. 
 
You asked the Plan to pay for the initial observation care. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says an appropriate modifier was not billed 
on the claim to indicate the code 99220 as not included to the global period of the minor surgical procedure. 
 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 99220 is initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
We looked at the file and Medicare rules. In this case, the observation services (99220) were rendered in 
conjunction with the surgical procedure code 29125. Payment for code 99220 is included in the global surgical 
payment for code 29125. No modifier was attached to 99220 to indicate it as a separate evaluation and 
management service from the global surgery period. Based on this information, we decided that Medicare rules 
for coverage of the initial observation care have not been met. Therefore, we decided that the Plan does not 
have to pay for the initial observation care (99220) provided on December 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cabazitaxel and Pembrolizumab.

You asked the Plan to pre-approve Cabazitaxel and Pembrolizumab. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Cabazitaxel and Pembrolizumab. Our reviewer says that the services are not medically necessary. Our physician reviewer found although both pembrolizumab and cabazitaxel are FDA approved for the indications prescribed (pembrolizumab for progression of disease after cisplatin and gemcitabine in urothelial cancer and cabazitaxel for prostate cancer with progression on docetazel) there is no data to support safety for combination therapy. A search of the literature revealed no studies to support safety of the combination of cabaxitaxel and pembolizumab. The service is not reasonable or medically necessary and safety and efficacy are unknown.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cabazitaxel and Pembrolizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Cabazitaxel and Pembrolizumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
January 21, 2022. 
 
You asked the Plan to pay for dental services. You say that you believe the Plan should pay for this. The Plan 
denied your request. The Plan says services provided by an out-of-network provider are not covered. 
 
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. The Plan covers covered 
dental services when they are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on January 21, 2022.