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

We decided that the Plan does not have to waive the coinsurance for anesthesia services provided on July 27, 2021, charged by your out of network provider.

You asked the Plan for to pay for these services in full. You do not believe this bill is correct. The Plan denied your request. The Plan says these services must be addressed under your Medicaid benefit by your out of network provider. 
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services). These services qualified under the Medicaid coverage. 

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to waive the coinsurance for anesthesia services provided on July 27, 2021, charged by your out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for imaging services provided to the enrollee on October 19, 2021.
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that the documentation support one unit of codes 73721-LT and
73721-RT were previously approved and paid with check number L4765444 on November 30, 2021. There is
no additional documentation supporting additional studies were done by the billing provider.
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 code. In this case. There is
insufficient documentation in the file to show these services were provided or required to be provided multiple
times. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does
not have to pay for imaging services provided to the enrollee on October 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (70450) services provided to the
enrollee on October 17, 2021.
You asked the Plan to pay for this claim. You say that these services should be paid. The Plan denied your
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. Maximus
overturned the Plans denial for lack of claim information in the case file. The Plan requested a reopen and
provided the required claim information.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that claims or claim lines
that have been determined to be exact duplicates of another claim or claim line are denied. However, such
denials may be appealed. We looked at the reopen request and the Medicare rules. The file includes evidence
that this imaging was reimbursed by the Plan on November 16, 2021, with check L4184805. Based on this
information, we decided that the Medicare rules for this claim have not been met. Therefore, we decided that
the Plan does not have to pay for computed tomography (70450) provided to the enrollee on October 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary for you to 
receive LTACH services. The Plan denied your request. The Plan says the guidelines for LTACH admission 
were not met and the enrollee's needs can be safely met in a hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to still be somewhat unstable with current treatment and 
requires short-term additional acute care services that can safely be administered at the current facility until 
more stable and appropriate for transfer. The enrollee does not require services at the LTACH that are not 
already available at the current facility. There are no services at the LTACH that the patient requires that are 
not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as 
the patient is not yet stable for transfer and as it would not be clinically necessary at this time. Completion of 
treatment at the current facility is recommended. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for an upper endoscopy, biopsy and
colonoscopy provided on October 12, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus applied the incorrect contract language. The Plan
says that you had both a colon screening, poly removal and EGD performed on the same day and that the cost
share applied was done so appropriately.
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 (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you must pay $330 cost share for outpatient diagnostic services.
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 charged for an upper endoscopy and colonoscopy provided on October
12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for refurbishment of hearing aid provided on April 29, 2022. 
 
You asked the Plan to pay for refurbishment of hearing aid. You say that you want the Plan to pay for the 
service. The Plan denied your request. The Plan says the service is not covered as it was provided by an out-of-
network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only they are provided by a contracted provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of refurbishment of hearing aid have not been met. Specifically, the service was received out-of-
network and therefore, is not covered. Therefore, we decided that the Plan does not have to pay for 
refurbishment of hearing aid provided on April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for recementing a crown on tooth #30 (D2920) provided on June 
8, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service should be covered as it is a less 
invasive procedure. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 23, 2021. 
Therefore, we decided that the Plan does not have to pay for recementing a crown on tooth #30 (D2920) 
provided on June 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for surgical services provided to the enrollee on October 29, 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 claim was billed correctly. The Plan requested a reopen and provided additional information.
The Plan states that code 64719 would be included in the billing of 64712 based on the anatomical site of the
incision. Code 64719-59-RT cannot be paid as billed due to its inclusion in other codes billed on the claim.
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, based on the
records provided and the surgical services described, this claim contains billing errors based on Medicare
guidelines. Therefore, we decided that the Plan does not have to pay for surgical services provided to the
enrollee on October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on June 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that due to the ongoing crisis it wasn't possible for 
you to get authorization before the services were rendered. 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 nursing facility 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 nursing facility care provided on June 22, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the platelet rich plasma (PRP) injections (0232T) 
provided from September 17, 2021, to January 27, 2022. 
 
You asked the Plan to reimburse you for PRP injections. You say that the injections denied as experimental. 
You say that you no longer require a cane to walk after the injections. You also say that these should be 
covered. The Plan denied your request. The Plan says PRP injections were not medically necessary. 
 
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 reimburse you for PRP injections. Our reviewer says 
that the PRP injections are not considered medically reasonable and necessary in this case. Our physician 
reviewer found PRP injections are considered experimental. The reviewer found that studies are needed to 
determine the optimal protocol for delivering platelet-rich plasma. The evidence is insufficient to determine the effects of the technology on health outcomes. Therefore, the reviewer found that the PRP injections are not 
medically reasonable and 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 PRP injections have not been met. Therefore, we decided that the Plan does not 
have to reimburse you for the platelet rich plasma (PRP) injections (0232T) provided from September 17, 
2021, to January 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH can properly take care of the 
enrollees current medical needs. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure fills a treatment gap for the 
enrollee when adequate relief from traditional conservative methods was not obtained. You also say that this 
procedure is safe and effective. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested Intracept procedure is considered experimental as additional research is 
needed. Therefore, the reviewer found that the Intracept procedure is not medically reasonable or 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an Intracept procedure (64628, 64629).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 clinical documentation shows that you have functional impairments however 
there are no documented active comorbidities that would require continued inpatient hospitalization during 
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for two additional physical therapy visits for the
enrollee.
You asked the Plan to provide coverage for these services. You say that these services are medically necessary.
The Plan denied your request. The Plan says while six additional visits were approved, Medicare coverage
criteria for the remaining two visits were not met. Maximus overturned the Plans denial stating continued
services would be beneficial.
The Plan requested a reopen and provided additional information. The Plan states that the records show this is
an 83-year-old with hemiplegia s/p a CVA requesting eight additional physical therapy sessions in which 6 of
those were approved by the plan on appeal with 2 remaining denied. To date, the enrollee has received (30)
physical therapy visits. The clinical information shows the enrollee to date responded positively to the
treatment plan as prescribed as evidenced by improved gait distance and standing balance. The enrollee had
twelve physical therapy visits and then eighteen additional physical therapy visits to finalize training on the
home exercise program. Medicare criteria were not met at the time of the appeal.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for
medically necessary outpatient therapy. Based on the records provided, the two remaining visits left on appeal
did not meet the required Medicare criteria for coverage. At the time of the appeal, further skilled services
beyond those approved by the Plan were not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Therefore, we decided that the Plan does not have to provide coverage
for two additional physical therapy visits for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
October 2, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that you did not receive any
services and never spoke to a nurse or doctor to explain why you were there. 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 a $90
copayment for each emergency room visit. The Plan provided records confirming you were seen in the
emergency room on October 2, 2021 for back pain. You have been asked to pay a $90 copayment for the
emergency room visit. This item/service falls within the emergency room visit 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 the emergency room visit provided on October 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiographic images (D0210), photographic images (D0350), 
and oral hygiene instructions (D1330) provided on February 3, 2022, and May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for the dental 
procedures. The Plan denied your request. The Plan says your benefit for the radiographic images has already 
been exhausted. Also, the denial of payment for the photographic images and oral hygiene instructions is 
correct, because they are not covered by the Plan. 
 
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 photographic images and oral 
hygiene instructions are not among those covered under this benefit. The record also shows your benefit for the 
radiographic images was exhausted on date of service of February 3, 2022. Therefore, we decided that the Plan 
does not have to pay for radiographic images (D0210), photographic images (D0350), and oral hygiene 
instructions (D1330) provided on February 3, 2022, and May 4, 2022.  
 
Your complaint about your experience with this provider 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service May 21, 
2022, to June 17, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that the code is payable. The Plan denied your 
request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. 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 S9328 billed for date of service May 21, 2022, to June 17, 2022.