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

We decided that the Plan does not have to pay for the removal of foreign body, external eye; conjunctival superficial (CPT code 65205) provided to the enrollee on August 30, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.
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 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 service. Our reviewer found documentation submitted was reviewed and does not meet criteria. Documentation does not include documentation of a foreign body removal. To cite the report, "The eye exam was performed on August 30, 2021, at 23:10, redness red. The associated symptoms are erythema, discharge and pain. The cause of the issue was trauma and Patient had foreign body removed at Grace clinic earlier today. The pupil size on the right eye was 3 mm. The right pupil was reactive. The left pupil was reactive. Using a woods lamp, fluorescein strips and tetracaine. The
examination revealed a corneal abrasion. No foreign body identified". CPT 65205 cannot be confirmed in this case. 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 service have not been met. Therefore, we decided that the Plan does not have to pay for the removal of foreign body, external eye; conjunctival superficial (CPT code 65205) provided to the enrollee on August 30, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76942) provided on December 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 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 76942 is a column II code to column I code 36556. 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 the services (76942) provided on December 4, 2020
Appeal type: Imaging
Decision: Unfavorable

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 71045 is a column II code to column I code 71046. 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 September 14, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the available records do not indicate any ongoing daily skilled needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and interpretation (CPT code 75885-26-59) provided to the enrollee on July 29, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says procedure codes 37241 and 36481 were approved, and procedure code 75885-26-59 was denied as "Inclusive to another Billed Code." The Plan states according to (CPT) code definitions and guidance, this case involves an inappropriate billing of CPT code 75885-26-59, and CPT code 75885-26-59 is not supported in the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We 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 service. Our reviewer found documentation submitted was reviewed and does not meet criteria. Procedure report does not support this service as a separate distinct service when a interventional vascular procedure is performed, as this procedure is inclusive of all radiological supervision and interpretation would be performed. 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 service have not been met. Therefore, we decided that the Plan does not have to pay for the percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and interpretation (CPT code 75885-26-59) provided to the enrollee on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99214) provided to the enrollee on March 5, 2020, by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit (CPT code 99214) provided to the enrollee on March 5, 2020, by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided from March 1, 2021,
through March 31, 2021.
You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share
responsibility for the services you received. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance).
According to your benefits there is a $125 copayment for each day of an inpatient hospitalization from days 21
to 40. There is a $0 copayment for days 1-20 and for additional days after 40. The day you are discharged is not
counted towards inpatient stays.
Review of the file shows that you were in inpatient care from February 23, 2021, through March 10, 2021, the
date you were discharged, this amounted to fifteen (15) days of inpatient care. You were readmitted on March
30, 2021, which was still within the benefit period as you had not been out of inpatient care for more than sixty
(60) days. You were in inpatient care from March 30, 2021, through April 15, 2021, which was another sixteen
(16) days of inpatient care. These days were added to the initial benefit period of 15 days inpatient care from
February 23, 2021, through March 10, 2021, which in total amounts to thirty-one (31) inpatient days. Per your
plan benefit, the first twenty (20) days are $0 cost share. Days 21-40 incur a $125 cost share per day. As you
were inpatient for 31 days in total, you incurred a total of 11 days of inpatient care at $125 cost share, totaling
$1375. The day the you are discharged is not counted towards inpatient stays.
The claims for the inpatient stay were billed separately and as the claim for April dates of service was received
earlier that the claim for services in March, the $1375 cost share has been applied to the dates on the claim
received latest, which is the claim for dates of service March 1, 2021, through March 10, 2021, and March 30,
2021, through March 31, 2021. The correct cost share amount has been applied to your inpatient stay. 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 SNF care provided from March 1, 2021, through March 31,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, knee; 3 views (CPT code 73562)
provided to the enrollee on May 21, 2021.
You asked the Plan to pay for the knee x-ray. You say that the claim should be paid. The Plan denied your
request. The Plan says the service is not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. CPT code 73562-50 (1 unit) remains not
supported. The documentation submitted did not include an x-ray report of knee with minimum of 3 views for
the billed date of service; therefore, the billed service cannot be verified. It is noted that multiple attempts were
made to contact the provider for additional information. Based on this information, we decided that Medicare
rules for coverage of the knee x-ray have not been met. Therefore, we decided that the Plan does not have to
pay for the radiologic examination, knee; 3 views (CPT code 73562) provided to the enrollee on May 21, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A02425, A0427) provided on September 21, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you thought these services would be covered in full and this cost is a financial strain. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. You are responsible for a $225 copayment per one-way ambulance trip.
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 $225 copayment for ambulance services.
You have been asked to pay a $225 copayment for the ambulance transportation. 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 ambulance transportation services (A02425, A0427) provided on September 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Coronavirus test (U0001) provided on August 3, 2021.
You asked the Plan to pay for the Coronavirus test. You say that you were required to get tested August 2, 2021 for your cruise which was leaving August 6, 2021 and you were unable to schedule a test at Plan-approved locations because they were all booked. You also say that you received this test at another location because the results were guaranteed overnight. The Plan denied your request. The Plan says Coronavirus testing for travel is not a medically necessary service covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as business establishments are not covered by Medicare. We looked at the file and Medicare rules. This testing was required by the cruise line for the purposes of routine travel. Based on this information, we decided that Medicare rules for coverage of the Coronavirus test have not been met. Therefore, we decided that the Plan does not have to pay for the Coronavirus test (U0001) provided on August 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the MRA, head; without contrast material(s) (CPT code
70544) provided to the enrollee on August 27, 2021.
You asked the Plan to pay for the MRA. You say that the claim should be paid. The Plan denied your request.
The Plan says the service is 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. In this case, we have confirmed that code 70551
is a column II code to column I code 70544. 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 the MRA, head; without contrast material(s) (CPT code 70544)
provided to the enrollee on August 27, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you are able to receive the help you need. You state
you like to be mobile and getting around has been difficult for you. You state that your daughter has been
trying to do things at home; however, you need more than what your daughter is able to provide. The Plan
denied your request. The Plan says your records do not show that you require daily skilled services that can
only be provided on an inpatient basis. The Plan states the services you require, such as additional therapy
services, can safely be received at a different setting, for example, home with home health, in residential care,
or home with close follow-up with your doctor.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found there is no documentation that you require
skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are
not required to provide medically necessary and reasonable treatment safely and effectively. You do require
skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required
to provide medically necessary and reasonable treatment safely and effectively. Daily skilled services are not
required. You do not require the services on an inpatient basis, only in a SNF setting. Services in the home with
home health care and a private duty caregiver (as needed) or in a long-term care facility on a part time basis
appear appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services received on
October 11, 2021.
You asked the Plan to waive the copayment for the services. You say that this should be waived, as you were
not triaged and no vitals were taken. The Plan denied your request. The Plan says the copayment was applied
appropriately.
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 $90
copayment for emergency room care.
You have been asked to pay a $90 copayment for the services. The services fall within the emergency room
care benefit category. This means that you have been asked to pay the correct amount based on your contract
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for emergency room services
received on October 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22867), for the enrollee.

You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the requested service is experimental and investigational; therefore, not covered by Medicare.

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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device and the coflex device are experimental for use in spine surgery. More research is needed to show safety and efficacy.

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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22867), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on March 18, 2021 and
coded as 88341 and 88342.
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 are not met. Maximus overturned the Plans denial for medical
necessity. The Plan requested a reopen and stated that this was not a medical necessity review but an
administrative review. The Plan states that the Procedure to Procedure (PTP) edits show there is a coding edit
between codes 88361 and codes 88341 and 88342. These codes have a modifier indicator of "1" indicating
column two codes will be denied without an appropriate PTP modifier. The submitted claim did not include a
PTP modifier making it ineligible for payment.
The Plan is correct in this case. The Plan must follow Medicare billing guidelines. Medicare rules state that
providers must submit claims with the appropriate codes and when necessary, the appropriate modifiers.
In this case, this claim cannot be paid due to the omission of the required modifier. Therefore, we decided that
the Plan does not have to pay for lab services provided to the enrollee on March 18, 2021, and coded as 88341
and 88342.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided for dental services.
You asked the Plan to pay for inpatient admission for tooth extraction. You say that these services should be
covered by the Plan. The Plan denied your request. The Plan says inpatient admission for dental services are
not covered. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did
not apply the correct contract criteria.
The Plan is correct in this case. Medicare does not cover dental services. 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 contract specifically states that hospitalization
for dental services is not covered. Therefore, we decided that the Plan does not have to pay for inpatient care
provided on February 26, 2021 for dental services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the MRA, head; without contrast material(s) (CPT code
70544) provided to the enrollee on October 4, 2021.
You asked the Plan to pay for the MRA. You say that the claim should be paid. The Plan denied your request.
The Plan says the MRI and MRA were performed on the same anatomic region during the same patient
encounter; the record does not support distinct technical studies.
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 70544. 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. The MRI and MRA
were performed on the same anatomic region during the same patient encounter; the record does not support
distinct technical studies. Therefore, we decided that the Plan does not have to pay for the MRA, head; without
contrast material(s) (CPT code 70544) provided to the enrollee on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four surgical placements of an implant body: endosteal implants (D6010 x4) provided on May 27, 2021.
You asked the Plan to pay for the endosteal implants. You say that you had chemotherapy for your breast cancer and your teeth had fallen out as a result. 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 four surgical placements of an implant body: endosteal implants (D6010 x4) provided on May 27, 2021