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

 
We decided that the Plan does not have to pay for the frames (V2020), trifocal lens (V2303), and the anti-
refelctive lens coating (V2750), provided on February 7, 2022. 
 You asked the Plan to pay for the eyewear. You say that the service should be covered. The Plan denied your 
request. The Plan says you have exhausted the Plan benefit for this service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services with up to a $300 allowance every year. 
 
We looked at the file and the Plan's rules. The total cost for the eyeglasses were $649. The benefit of $300 
allowance was applied to the purchase, leaving you with a members responsibility of $349. Based on this 
information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we 
decided that the Plan does not have to pay for the frames (V2020), trifocal lens (V2303), and the anti-refelctive 
lens coating (V2750), provided on February 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not meet severity 
of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blepharoplasty (15823) provided on October 18, 2021. 
 
You asked the Plan to pay for the blepharoplasty (15823). You say that modifier 50 has not been recognized in 
the past so the claim was submitted with right and left modifier. The Plan denied your request. The Plan says 
CPT codes 15823 has an MUE value of 1, but 2 units were billed. 
 
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 15823 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 of the 
blepharoplasty (15823) have not been met. Therefore, we decided that the Plan does not have to pay for the 
blepharoplasty (15823) provided on October 18, 2021.  
 
We note that it appears a corrected claim was submitted directly to Maximus during the review of this case. We 
cannot act on or process claim corrections. Corrected claim information may be submitted directly to the Plan 
for further review. We are only permitted to make a decision based on the claim information reviewed by the 
Plan for payment. Please submit any corrections or additional claim information directly to the Plan.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot/cold packs (97010) provided to the enrollee on December 
6, 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 this code has a status indicator of "B." 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 We find that CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the services have not been met. Therefore, we decided that the Plan does not have to pay for hot/cold packs 
(97010) provided to the enrollee on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic 
service (99053) provided on September 15, 2021. 
 
  You asked the Plan to pay for services provided at 24-hour facility, in addition to basic service (99053). You 
say that the correct CPT and ICD10 were assigned, and no coding changes are required. You say that the 
services were medically necessary, and the attached medical records support the claim as originally billed. The 
Plan denied your request. The Plan says CPT code 99285 has been overturned and CPT code 99053 remains 
denied as bundled services are not eligible for separate reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of services provided at 24-hour facility, in addition to basic service (99053) have not been met. Therefore, we 
decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic service 
(99053) provided on September 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance transportation services. 
 
You asked the Plan to pre-approve ambulance transportation services. You say that the enrollee goes to dialysis 
3 times a week, is bed confined, and suffers with poor trunk control. You say that the enrollee needs a stretcher 
to get to and from dialysis. You say that if the enrollee cannot attend dialysis because a stretch cannot get to 
them, then they could potentially die. The Plan denied your request. The Plan says they did not receive medical 
records which supported that the criteria for coverage of non-emergent ambulance transportation have been 
met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance transportation services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation 
does not support that other means of transport (such as stretcher van) are contraindicated for the enrollee. The 
documentation does not support that the enrollee needs the expertise, services, and lifesaving and life-
sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation 
does not support that the ambulance transport is medically reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance transportation services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ambulance transportation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection (62320) provided on November 15, 2021. 
 
You asked the Plan to pay for the injection. You say that the service should be covered. The Plan denied your 
request. The Plan says the provided documentation does not include date or signatures. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the injection (62320) provided on November 15, 2021 have been met. Specifically, the file does not show that the records included are for the 
dates of service in this case, nor are they signed by the provider. Therefore, we decided that the Plan does not 
have to pay for the injection (62320) provided on November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive examination provided on December 23, 2021, 
billed with code 99397. 
 You asked the Plan to pay for the preventive examination. You say that you feel that this has been denied 
incorrectly. You feel that this needs to be resolved because you should not have to pay for something that 
Medicare covers. The Plan denied your request. The Plan says the service rendered was a non-Medicare-
covered visit. Your Plan does cover this service as an extra benefit, but you exhausted this with a visit to 
another provider. 
 
The Plan must follow Medicare rules. Medicare rules say that generally routine services unrelated to an illness 
or injury are noncovered. However, the ACA established coverage for an AWV once per year. Your Plan offers 
a full preventive physical exam in addition to what is covered by Medicare.   
 
We looked at the file and Medicare rules. The services provided on the date of service at issue were not billed 
as a Medicare-covered AWV, nor were the services that were provided by another physician on August 31, 
2021. Both were billed with code 99397, a Medicare non-covered code, which is used to represent annual 
preventive physical exams. Because the Plan made payment for this code for the services in August 2021, the 
benefit for annual preventive physicals was exhausted at the time of the service at issue. Based on this 
information, we decided that Medicare rules for coverage of the preventive examination have not been met. 
Therefore, we decided that the Plan does not have to pay for the preventive examination provided on December 
23, 2021, billed with code 99397.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thoracic spine injection services billed on November 1, 
2021. 
 You asked the Plan to pay for the billed services. You say that subarachnoid opioids have been found very 
effective for decreasing pain. The Plan denied your request. The Plan says there is insufficient documentation 
of response to prior injections. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. We find that CPT code 62320 is not supported. The records provided do not 
include the date the services were provided. 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 the thoracic spine 
injection services billed on November 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan of the abdomen and
pelvis without contrast (74176) provided on September 8, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient decision information in the case file. The Plan requested a reopen and provided additional
explanation. The Plan states and provided documentation to show that a Procedure to Procedure (PTP) edit
exists between 74176 and 74177. Maximus overturned the upheld decision stating, "There is not a National
Correct Coding Initiative (NCCI) edit that exists between these codes. The Plan states that the provider billed
74177 but has not forwarded any documentation to support this." The Plan respectfully a reconsideration of
the overturned decision as the Plan has provided the supporting documentation showing that the denial applied
correctly. A search of CMS.Gov PTP edit shows denied code 74176 has an existing relationship with billed and
paid code 74177. This code was billed by the same provider on the same date of service. Those documents
were provided with the reopen. Per National Correct Coding Initiative (NCCI), each edit table contains edits
which are pairs of HCPCS/CPT codes that in general should not be reported together. Each edit has a Column
One and Column Two HCPCS/CPT code.
If a provider reports the two codes of an edit pair, the Column Two code is denied, and the Column One code is
eligible for payment. Medicare coding rules indicate the CPT code 74176 is found under Column Two of the
edit pair CPT code 74177 found under Column One. Therefore, Medicare billing criteria were not met.
The Plan is correct in the case. 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, payment
for code 74176 cannot be made due to a billing error. Medicare rules for coverage of this service have not been
met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan of the
abdomen and pelvis without contrast (74176) provided on September 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the total knee arthroplasty represented by code 27447 and the
arthrocentesis represented by code 20610 provided on October 21, 2020.
You asked the Plan to pay for code 20610 and 27447. You say that this claim should be paid. The Plan denied
your request. The Plan says Medicare billing criteria were not met for 20610 and code 27447 was previously
paid. Maximus partially overturned the Plans denial for lack of documentation showing code 27447 was paid.
The Plan requested a reopen and provided documentation to show payment.
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 CPT code. In this case, we have
confirmed that code 20610 is a column II code to column I code 27447. 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 code 20610 as billed and it has been
confirmed code 27447 was paid.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce cost share for outpatient services provided on
February 9, 2021.
You asked the Plan to waive or reduce 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 share was charged based on the services provided and the
Plan contract agreement. Maximus partially overturned the Plans denial. The Plan requested a reopen and
stated that Maximus did not apply the correct contract language. The Plan states that the claim images show
you were admitted to outpatient care and treated for diagnosis code D45 Polycythemia vera. Polycythemia
Vera Treatment options include Phlebotomy. This is often the first treatment for people who have
polycythemia vera. Your doctor takes blood from your vein, so you have fewer blood cells. It's a lot like
donating blood.
Per the medical definition of this code, the service (CPT Code 99195) is not a diagnostic procedure (which
would be used to determine if the member had a condition) and instead it proves this is a therapeutic blood
service (which is used to treat the members condition). Per the member's 2021 Evidence of Coverage, Chapter
4: Medical Benefits Chart (what is covered and what you pay), page 4-50 to 4-53: Outpatient Surgery and
Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers, if you are
having surgery in a hospital facility, you should check with your provider about whether you will be an
inpatient or outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are
an outpatient and pay the cost-sharing amounts for outpatient surgery. Even if you stay in the hospital
overnight, you might still be considered an "outpatient." This is called an "Outpatient Observation" stay. If you
are not sure if you are an outpatient, you should ask your doctor or the hospital staff. The cost share for this
type of service is typically $395. In this instance you were only charged $121.01.
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 pay $395 copayment for outpatient facility services. In this case, based on the claim
submitted by your provider, you were only asked to pay $121.01. 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 or
reduce cost share for outpatient services provided on February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the fundus photography with interpretation and report
(92250) and the medical eye exam (92014) provided to the enrollee January 25, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says code 92250 is not supported by the medical records and code 92014 was previously
paid. Maximus partially overturned the Plans denial stating the Plan had not provided documentation to show
code 92014 was previously paid. The Plan requested a reopen and provided the required documentation.
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. We now find codes 92014
and 92250 are the exact duplicate of a claim for services previously processed and paid. Therefore, we decided
that the Plan does not have to pay for the fundus photography with interpretation and report (92250) and the
medical eye exam (92014) provided to the enrollee January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection procedure (20610) and surgical trays (A4550)
provided to the enrollee on April 23, 2021.
You asked the Plan to pay for any of these services. You say that this claim should be paid. The Plan denied
your request. The Plan says code 20610 was previously paid and code A4550 does not meet Medicare billing
criteria. Maximus partially overturned the Plans denial, stating no paid claim information was provided for
code 20610. The Plan requested a reopen and provided proof of payment for code 20610.
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, code A4550
does not have a separate payment when billed on an ambulatory surgical center claim. The Plan has provided
documentation to show code 20610 was previously paid on November 5, 2021. Therefore, we decided that the
Plan does not have to pay for the injection procedure (20610) and surgical trays (A4550) provided to the
enrollee on April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2750) for tooth # 7. 
 
You asked the Plan to pre-approve the dental service. You say that your tooth keeps breaking. You say that it 
needs treatment.  You say that you have pain and discomfort. You also say that when you eat, food goes inside 
the hole. The Plan denied your request. The Plan says that your tooth does not have a lot of tooth missing from 
cavity or decay. The Plan also says that a crown is not necessary. 
 
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 file shows that the Plan did not provided legible documentation 
to support the denial. We requested this information but nothing was received. Therefore, we decided that the 
Plan has to pre-approve a crown (D2750) for tooth # 7.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on December 12, 2020,
under codes 73220, 82565 and A9585.
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 payment for these services would have been included in the facility claim. Maximus
overturned the Plans denial because the Plan had not provided a copy of the facility claim. The Plan requested a
reopen and provided a copy of the facility claim. The Plan says that this claim was administratively upheld
because they are pre-admission services and payment would be included in the amount the Plan paid for the
Inpatient facility claim. This claim was paid on January14, 2021.
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, payment for
these services would have been included in the facility claim and cannot be separately billed. Based on this
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we
decided that the Plan does not have to pay for lab services provided to the enrollee on December 12, 2020,
under codes 73220, 82565 and A9585.