Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injections for a cholangiogram provided 
on April 01, 2022, to May 03, 2022. 
 
You asked the Plan to waive the copayment for the injections for a cholangiogram. You say that you would not 
have needed these procedures if you had your gallbladder removed sooner. 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 $300 
copayment for outpatient hospital surgery services. 
 
You have been asked to pay a $300 copayment for the injections for a cholangiogram. This item/service falls 
within the outpatient hospital surgery services 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. The file shows you had 2 injections performed on April 1, 2022, and May 3, 
2022. The EOC says there is a $150 for outpatient surgery services. The total for both injections is $300. Therefore, we decided that the Plan does not have to waive the copayment for the injections for a 
cholangiogram provided on April 01, 2022, to May 03, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on May 10, 2022. 
 
You asked the Plan to pay for the testing services. You say that the medical records support the billed charges. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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 the pharmacogenomics testing panel was not billed with a single code as required. 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 gene panel testing provided on May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 5, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on March 04, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that there is no charge for this 
when done in a providers office. 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 $325 
copayment for Outpatient hospital facility visit. 
 
You have been asked to pay a $325 copayment for outpatient surgery. This item/service falls within the 
Outpatient hospital facility 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 
outpatient surgery provided on March 04, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assessment of and care planning provided on April 27, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for assessment of and care planning. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says the services were provided out-of-network and 
were not approved in advanced. 
  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 assessment of and care planning provided on April 
27, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital visit provided on 
May 03, 2022. 
 
You asked the Plan to waive the copayment for the outpatient hospital visit. You say that you have never had 
this charge before. 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 
$115.98 copayment for outpatient hospital services. 
 
You have been asked to pay a $115.98 copayment for the outpatient hospital visit. This item/service falls 
within the outpatient hospital services 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. The EOC says there is a $325 copayment for outpatient hospital services. Since 
the allowed amount for this procedure is $115.98, you are only responsible for the lesser amount. Therefore, we 
decided that the Plan does not have to waive the copayment for the outpatient hospital visit provided on May 
03, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient service provided on February 21, 
2022, to February 28, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you went to was a 
building/wellness facility and not a hospital. 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 $295 
copayment for each Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay $295 copayment for outpatient surgery. This item/service falls within the 
Medicare-covered outpatient hospital facility 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 outpatient service provided on February 21, 2022, to February 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you broke your back and cannot be released to 
independent care at home. You need physical therapy and assistance due to immobility. You need to be 
rehabilitated back to function in order go back home. The Plan denied your request. The Plan says the criteria 
for admission to the Acute Inpatient Rehabilitation setting have not been met. Your ongoing skilled therapy and 
nursing needs can be provided at a lower level of care. 
 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different level of care. 
 
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 acute IRF admission and services.
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 this is the safest plan for the enrollee, 
allowing the highest potential for enrollee's recovery and preventing further deterioration and the best use of 
medical management. The Plan denied your request. The Plan says the criteria for admission to the LTACH 
have not been met. The enrollee's medical needs are being met in the current acute 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 transfer to the LTACH is not medically necessary as the enrollee 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the radiation therapy provided on April 21, 
2022. 
 
You asked the Plan to waive the copayment for the radiation therapy. You say that you did not have treatment 
that day. 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 $60 
copayment for radiation therapy. 
 
You have been asked to pay a $60 copayment for the radiation therapy. This item/service falls within the 
radiation therapy 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. The records show that the radiation therapy was performed on April 21, 2022. Therefore, we 
decided that the Plan does not have to waive the copayment for the radiation therapy provided on April 21, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 20, 2021. 
 
You asked the Plan to pay for the services provided. You say that a screening test was performed based on the 
enrollee's medical history. The Plan denied your request. The Plan says this testing is not separately billed. 
 
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. The testing described by billed code 83789 is considered specimen 
validity testing which is not separately payable.  Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on December 20, 2021.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for unspecified items/services (A9270GY). We decided that the Plan does 
not have to waive the coinsurance for Medicare-covered Part B drugs.  
 
You asked the Plan to pay for outpatient medical services provided on June 9, 2022. You say that you were told 
the surgery was covered due to your medical condition but received a bill charging an additional $780.34, 
along with the $375 copayment. The Plan says that the cost-share applied is correct. 
 
  We decided that the Plan has to pay for the unspecified items/services billed with code A9270GY.  
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). Neither the Plan nor the claim submitted by the provider identifies the 
items or services represented by codes A9270-GY. Without this information, we cannot determine what items 
or services are intended to be represented by the use of A9270-GY and whether these item/services may be 
covered by Medicare or the Plan. Therefore, the Plan did not provide adequate documentation needed to prove 
or show that services billed with code (A9270GY) are not covered by the Plan. Therefore, we decided that the 
Plan has to pay for the unspecified items/services (A9270GY).  
 
We also decided that the Plan does not have to waive the coinsurance for Medicare-covered Part B 
drugs. 
 
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-covered Part B prescription drugs. You are asked to pay a coinsurance of $15.85, 
which is 20% of the allowed amount for Medicare-covered Part B prescription drugs ($79.26 allowed x 20% = 
$15.85). Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare-covered Part 
B prescription drugs provided on June 9, 2022. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mammography on May 24, 2022. 
 
You asked the Plan to waive the copayment for mammography. You say that you want to appeal the amount 
being charged. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $45 copayment for each basic imaging service (e.g., general x-rays or ultrasound). Covered services 
include but are not limited to other outpatient diagnostic tests. 
 
The enrollee has been asked to pay a $45 copayment for mammography. This item/service falls within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for mammography on May 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on October 8, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code is 
not substantiated by the clinical 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. 
 
In this case, the CPT Code Manual definition of code 41135 is glossectomy; partial, with unilateral radical neck 
dissection. We find that CPT code 41135 is not supported in the medical record. There is a more 
comprehensive code available for the hemiglossectomy services 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 surgery services provided on October 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
April 26, 2022. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you feel you should not be 
held responsible for this bill because you were not informed that you should get another x-ray. The Plan denied 
your request. The Plan says your benefit for the requested 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 service was exhausted on date of service January 5, 2021. Therefore, we 
decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on April 
26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lens surgery services (00142) provided on June 25, 2020.
You asked the Plan to pay this claim. The Plan denied your request. The Plan says Medicare billing criteria
were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan
requested a reopen and provided additional information. The Plan states that the provider submitted a claim for
code 00142-QX-QS-22 which is anesthesia for procedure on the eye; lens surgery for June 25, 2020. The Plan
states the 2020 National Physician Fee Schedule Relative Value File shows that code 00142 has a global day
indicator of "XXX". The Medicare guidelines indicate modifier 22 should only be reported with codes that
have a global period of 0,10, or 90 days.
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 required the
appropriate modifies. In this case, this claim could not be paid as billed due to the use of an inappropriate
modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan
does not have to pay for lens surgery services (00142) provided on June 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroid testing (84443) provided on June 1, 2022. 
 
You asked the Plan to pay for procedure code 84443. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 We looked at the file, the Plans contract, and Medicare rules. Medicare has limited ICD-10-CM codes that 
support medical necessity and provide coverage for procedure code 84443. Diagnosis code D75.89 as billed in 
this case is not a covered diagnosis code per Medicare guidelines. Therefore, we decided that the Plan does not 
have to pay for the thyroid testing (84443) provided on June 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on October 13, 
2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services provided by an OON provider. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says 
authorization was not obtained for the services provided by an out-of-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 the outpatient hospital services provided on 
October 13, 2020, by an out-of-network (OON) provider.