Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for the enrollee.
You asked the Plan to pre-approve a crown. You say that a crown is necessary and the only clinically
acceptable method of treatment. The Plan denied your request. The Plan says that the requested service for
tooth #20 is not clinically necessary. Maximus overturned the Plans denial based on the information in the case
file. The Plan requested a reopen and provided corrected information.
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 Plan covers a crown when
the services are medically necessary and reasonable.
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 a crown. Our office initially reviewed
this case for an amalgam (D2150).
The Plan has confirmed that this service was not the actual service being requested and that the request was for
a crown (D2740). Our reviewer says that a crown is not medically reasonable and necessary for the enrollee. A
review shows that there is a two-surface restoration (DO surfaces) in tooth #20 which is defective.
Replacement of this restoration with another restoration is the standard of care. Our physician reviewer found
that the enrollee's condition does not meet criteria for coverage of a crown.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have
to pre-approve a crown (D2740) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an out of network office visit provided to the enrollee on
February 9, 2022.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says the enrollee's out of network deductible had not been met at the time of
service. Maximus administratively overturned the appeal for incorrect contract information. The Plan requested
a reopen and provided the correct contract for review.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. The enrollee's contract with the Plan says that there is $1000 deductible which
applies to out of network services. The Plan has followed Medicare rules by clearly disclosing in the contract
that there is $1000 deductible which applies to out of network services. This cost sharing is a contractual
obligation that had not been met at the time these services were provided. Therefore, we decided that the Plan
does not have to pay for an out of network office visit provided to the enrollee on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a ferric derisomaltose injection and an IV 
infusion provided on November 17, 2021 
 
You asked the Plan to waive the cost share for a ferric derisomaltose injection and an IV infusion. You say that 
you cannot afford to pay this. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must 
pay a $295 copayment outpatient surgery and other medical services provided at hospital outpatient facilities 
and ambulatory surgical centers.  
 You have been asked to pay $497.36 for a ferric derisomaltose injection. You have also been asked to pay 
$194.09 for an intravenous infusion. The ferric derisomaltose injection falls within the Medicare Part B 
prescription drugs benefit category. The intravenous infusion falls within the outpatient surgery and other 
medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category.  
 
Date of Service Service Plan 
Allowance 
Cost Per 
Contract 
Your 
Responsibility 
November 11, 
2021 
Injection $2,486.80 20% 
Coinsurance 
$497.36 
November 11, 
2021 
Infusion $194.09 $295.00 $194.09 
Total    $691.45 
 
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 cost share for a ferric derisomaltose injection and an IV infusion provided 
on November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 19, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that our contract with the Plan is a group contract. You 
say to please review and reprocess the claim.  The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
 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 an office visit provided on April 19, 2022, by an 
OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 9, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary/rest home visit and psychotherapy provided on 
April 12, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary/rest home visit and psychotherapy. You say that the services were 
medically necessary, and you are appealing with supporting records. The Plan denied your request. The Plan 
says the enrollee must receive care from a network provider. 
 
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 a domiciliary/rest home visit and psychotherapy 
provided on April 12, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a health club membership purchased on January 1, 
2021. 
 
You asked the Plan to reimburse you for a health club membership. You say that you thought you had 24 
months to submit reimbursement form. The Plan denied your request. The Plan says they received your 
reimbursement form on May 5, 2022, which was after the March 31st deadline. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when reimbursement requests are received by the Plan by no later than March 31st of the following year. 
 
The Plans rules for coverage of gym benefits have not been met because the reimbursement form was not 
received before the March 31st deadline. Therefore, we decided that the Plan does not have to reimburse you 
for a health club membership purchased on January 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36470 billed for date of service March 29, 
2022. 
 
You asked the Plan to pay for procedure code 36470. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 36470 is bundled into 
payment for code 36478. 
 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 36470 
is a column II code to column I code 36478. 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 36470 billed for date of service March 29, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation shows that the enrollee has multiple active medical issues (supratherapeutic INR, 
hematoma with sciatic neuropathy, electrolyte derangement). Plan denied because of medical stability 
(hematoma) however cardiology consult recommends close monitoring and non-surgical intervention. 
Evaluating therapists (PT, OT) recommend intense therapy and there are several documented active functional 
issues (several fractures and sciatic compression). IRF criteria has been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 lab services provided on February 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76513 billed for date of service February 1, 
2022. You asked the Plan to pay for procedure code 76513. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76513 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 procedure code 76513 billed for date of 
service February 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 13, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on January 27, 2022.
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 the Medicare billing criteria for code 992236 were not met. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the time requirement to the
code criteria. The Plan noted that based on the chart notes, the provider did not document the minimum time
required to bill 99356 (prolonged services) in addition to 99223 (hospital admit). The Medicare billing
guidelines state that the provider must show at least 30 minutes of time beyond the time listed for the base code
to report 99356 in addition to the base code. Code 99223 is the base code in this case, and the time listed for
code 99223 is 70 minutes. That means the provider would need to show a total time of at least 100 minutes
caring for the enrollee to support billing 99356 in addition to 99223. This provider documented only 80
minutes total time caring for the enrollee.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case the time spent
with the enrollee does not meet the criteria for the codes reported on the claim. Medicare rules for coverage of
these services have not been met. Therefore, we decided that the Plan does not have to pay for physician
services provided to the enrollee on January 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the enrollee to receive 
IRF care. The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not met 
and the enrollee's needs can be met at a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted to the hospital on October 1, 2022, for radiation proctitis and sepsis. The enrollee 
required a colostomy on October 10, 2022. The enrollee was discharged home with home health services on 
October 19, 2022. The enrollee is currently at home and does not require the intensity of medical oversight 
provided in the acute inpatient rehabilitation setting. The enrollee does not require rehabilitation nursing for 
complex wound care, parenteral nutrition or tube feedings, tracheostomy management or management of 
neurogenic bowel or bladder. The enrollee has not had an acute change in their neurological status. The 
enrollee's medical and rehabilitation needs do not require the intensive interdisciplinary approach provided on 
acute inpatient rehabilitation. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program at least 3 hours a day and 5 days a week, or 15 hours 
over seven consecutive days. As of October 26, 2022, the enrollee required minimal assistance for bed mobility 
and transfers and stand by assistance for wheelchair mobility. The enrollee requires maximum assistance for 
lower body dressing and is dependent for toileting. The enrollee has had a functional decline from his baseline 
level of function and would likely benefit from therapy, but they do not require the intensity of therapies 
provided on acute inpatient rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab tests (88305, 88312) provided on June 3, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab tests. You say that the enrollee does not come to the OON lab for the 
testing. The Plan denied your request. The Plan says this testing is not covered because it was provided OON 
without prior authorization. 
 
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 lab tests (88305, 88312) provided on June 3, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 3, 2021.
You asked the Plan to pay for this claim as billed. You say that these services should be paid by the Plan. The
Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans
denial stating the medical records support the services billed. The Plan requested a reopen and stated the issue
was with the modifier billed on the claim. The Plan explained that this claim denied because this service was
inappropriately billed. This service was not billed with the appropriate modifier. The Plan states the provider
needed to bill this service with Modifier 52 - to indicate partial reduction, cancellation or discontinuation of
services for which anesthesia is not planned. The modifier provides a means for reporting reduced services
without disturbing the identification of the basic service.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes and when necessary, the
appropriate modifiers. The original Maximus coder did not review the issue with the modifier.
The Plan did not deny payment based on the service provided but on how the service was billed. The claim in
the file shows the omission of the appropriate modifier. Medicare rules for coverage of this claim as billed have
not been met. Therefore, we decided that the Plan does not have to pay for surgical services provided to the
enrollee on August 3, 2021.