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

 
We decided that the Plan does not have to pay for inpatient initial observation provided on January 04, 2022, to 
January 05, 2022. 
 
You asked the Plan to pay for inpatient initial observation. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for inpatient initial 
observation provided on January 04, 2022, to January 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on December 21, 2021. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
December 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care associated with an elective 
surgery. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient admission is medically 
necessary. The Plan denied your request. The Plan says there is no documentation provided to support the 
expectation the enrollee will require a greater than two midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   

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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that detailed documentation is not evident regarding a significant past and/or current 
medical history that would place this enrollee at increased risk for peri-surgical complications requiring an 
inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the record does not show that at the time of 
inpatient admission, the admitting physician would reasonably expect that the enrollee's necessary hospital 
care would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care associated with an elective surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the swallow function x-ray with contrast (74230) and upper 
gastrointestinal tract x-ray with contrast (74240) provided on September 7, 2022. 
 
You asked the Plan to pay for the swallow function x-ray and upper gastrointestinal tract x-ray. You say that 
the enrollee was consulted in the skilled nursing facility. You also say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures and examinations which are not 
covered under the portable x-ray provision include procedures involving the use of contrast media.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the swallow function x-ray and upper gastrointestinal tract x-ray have not been met. Therefore, we 
decided that the Plan does not have to pay for the swallow function x-ray with contrast (74230) and upper 
gastrointestinal tract x-ray with contrast (74240) provided on September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunizations billed under codes G0009, 90732, G0008, 
90694 provided on September 29, 2022. 
 
You asked the Plan to pay for immunizations billed under codes G0009, 90732, G0008, 90694. You say that 
you are appealing the claim payment denial. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for immunizations billed 
under codes G0009, 90732, G0008, 90694 provided on September 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mammography services provided on November 15, 2022. 
 
You asked the Plan to pay for mammography services. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for mammography services 
provided on November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported as 
billed. 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 March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies provided on October 04, 2022. 
 
You asked the Plan to pay for medical supplies. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for medical supplies 
provided on October 04, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituximab. 
 
You asked the Plan to pre-approve Rituximab. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Rituximab. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
Ruxience and Truxima would likely be less effective, and/or would likely have adverse effects for the enrollee 
in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituximab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Rituximab.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 24, 2021 
to October 4, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
dispute the removal of the diagnosis codes. The Plan denied your request. The Plan says there was a change 
from DRG 308 to 310, due to the removal of the secondary diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 308. 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 pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the records did not support DRG 308 in this case. The appropriate DRG is 309. The review has determined 
that the documentation did not support secondary diagnosis code G93.41 - metabolic encephalopathy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 24, 2021 to October 4, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a panoramic radiographic image (D0330), provided on 
September 26, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you went in for your annual cleaning. You 
also say that the x-rays were done and should be covered since it was the only time they were taken this year 
along with the other services received. The Plan denied your request. The Plan says you are responsible for any 
charged amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. The record shows your benefit for the panoramic radiographic image (D0330) was exhausted on date of service 
October 19, 2019. You have been asked to pay the difference between the out-of-network providers charges 
and the Plans payment. 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 pay more for a panoramic radiographic image 
(D0330), provided on September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to issue additional reimbursement for the hearing aids (V5298 x 2) purchased on 
January 24, 2022. 
 
You asked the Plan to issue additional reimbursement for these items. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the claim 
was incorrectly processed in this case.  
 
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 Plan has stated that the claim was incorrectly processed in this 
case showing three (3) hearing aids, rather than two (2) hearing aids and a hearing aid charger purchased. 
However, the Plan did not send an updated claim to clarify what hearing aids were processed and what you 
actually owe. The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we 
decided that the Plan has to issue additional reimbursement for the hearing aids (V5298 x 2) purchased on 
January 24, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 14, 2022. 
 
You asked the Plan to pay for office visit. You say that you are asking for the denial to be reconsidered for 
payment. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99205 provided on September 20, 2022. 
 
You asked the Plan to pay for procedure code 99205. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing 
of code 99205. 
 
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 99205 is Office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and high 
level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on 
the date of the encounter. 
 We find that CPT code 99205 is not supported in the medical record. Specifically, the medical records do not 
note that 60-74 minutes of total time was spent with the enrollee on September 20, 2022. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99205 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99205 provided on September 20, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on April 4, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. 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 the laboratory service provided on April 4, 2022, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service October 5, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service October 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dialysis services provided to the enrollee from October 7, 2020, and October 26, 2020.
You asked the Plan to pay for the dialysis services. You say that the claim denied but the enrollee did not receive any injections, only dialysis. The Plan denied your request. The Plan says that the Medicare billing criteria were not met. Maximus overturned the Plan's denial. The Plan requested a reopen and provided additional information. The Plan noted that the date that was submitted for the occurrence code "51" is not the date of the last reading taken during the billing period. The date span that was billed was October 7, 2020, through October 26, 2020, and the occurrence date for the occurrence code "51" was billed as October 28, 2020, which does not fall into the "billing period".
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed due to a discrepancy with codes submitted and the dates submitted. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for the dialysis services provided to the enrollee from October 7, 2020, and October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95861 billed for date of service April 25, 
2022. 
 
You asked the Plan to pay for procedure code 95861. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95861. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 95861. Based on this information, 
we decided that Medicare rules for coverage of procedure code 95861 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 95861 billed for date of service April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve a SCS trial. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that dorsal column stimulators may be covered as 
therapies for the relief of chronic intractable pain under certain circumstances. 
 
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 SCS trial. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee does not have an evidence-
based indication for this procedure. She has other evidence-based alternatives. The psychological clearance by 
a social worker does not meet the criteria of the NCD. The request is 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 a SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) trial.