Persius/hicric huggingface dataset:
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 you would like to appeal the admission 
to LTACH. The Plan denied your request. The Plan says the transfer to LTACH was denied because the 
enrollee is receiving appropriate in-patient acute care. 
 
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 the patient was admitted to the acute care hospital with acute respiratory failure from 
pneumonia and right-sided pleural effusion requiring chest tube, intubation, trach and PEG placement. The 
course was complicated by needing wound debridement and antibiotics for sacral wound and coccyx 
osteomyelitis. Recent notes describe the patient as weaning and now tolerating basic wound care and trach 
collar but is still on reduced amounts of high flow oxygen. 
 
  The patient appears to be more stable and improving and should only require short-term additional acute care 
services that can safely be completed at the current facility until more appropriate for a lower level of care. The 
patient 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 LTACH is not medically necessary as it would not be clinically advantageous 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for not medically necessary services (S9986) provided on 
December 10, 2021. 
 
The enrollee asked the Plan to pay for not medically necessary services. The enrollee says that the services at 
issue were a medical necessity. The Plan denied the enrollees request. The Plan says rules for payment have 
not been met because the services at issue are not a covered benefit. 
 
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 S9986 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9986 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of not medically necessary services have not been met. Therefore, we decided that the Plan does not 
have to pay for not medically necessary services (S9986) provided on December 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide visits. 
 
You asked the Plan to pre-approve home health aide. You say that the combination of your conditions means 
that you can no longer care for yourself at home or get around without assistance. The Plan denied your 
request. The Plan says the denial of authorization for home health aide services is correct. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide. Our reviewer says 
that you do not meet the Medicare criteria for home health aide services. Our physician reviewer found the 
services of a home health aide are not shown to be medically necessary to assist in the treatment of illness or 
injury. Your care needs appear to be custodial and long-term. As such, home health services 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 home health aide have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided on July 1, 2020.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says you did not have prior authorization for out of network care. Maximus
overturned the Plans denial for insufficient information regarding the status of the providers. The Plan
requested a reopen and confirmed all the providers used were out of network.
The Plan is correct in this case. 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 in this case is not a
network provider with the Plan. The Plan had network providers available who could have provided the
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 services. Therefore, we decided that the Plan does not have to pay for out of network services
provided on July 1, 2020, by the provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH will meet the daily acute 
care needs of the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for the approval of LTACH services. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography of the thorax (71250). 
 
You asked the Plan to pre-approve the CT. You say that the scan may give you some additional imaging of the 
potential lesion. The Plan denied your request. The Plan says that the records show that enrollee may have a 
tumor or growth under his skin, but a study similar to the one requested has recently been performed. The 
results of that study showed what was needed in order to treat the enrollee's condition. The Plan also says that 
no additional imaging is necessary at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT. Our reviewer says that the 
requested CT of the thorax (71250), in this case, is medically reasonable or necessary. Our physician reviewer 
found the follow-up diagnostic tests including x-rays of the left shoulder and magnetic resonance imaging of 
the left shoulder did not show the pathology. Additional diagnostic testing is indicated to ensure correct 
diagnosis (differential includes sarcoma) prior to treatment. Our reviewer also found that the requested CT of 
the thorax (71250), in this case, is 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 the CT have been met. Therefore, we decided that the Plan has to pre-approve a 
computed tomography of the thorax (71250).  
 
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 dialysis services provided to the enrollee from January 2,
2021, to March 31, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says the claim was submitted with an inappropriate modifier. Maximus
overturned the Plans denial for a lack of claim documentation in the case file. The Plan requested a reopen and
provided the required claim information.
The Plan further stated that the provider was notified that a corrected claim was needed without the AX
modifier. The Plan reports the staff they spoke to expressed that they would handle the claims in a different
way on their end. The Plan states they reminded this person that a waiver of liability was signed, and they
could not bill the enrollee.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes and modifiers. In this case,
this claim cannot be paid as billed due to the inappropriate use of the AX modifier. 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 dialysis services provided to the enrollee from
January 2, 2021, to March 31, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on November 17, 2021, and 
December 1, 2021. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says services that are not 
covered by Medicare include; services occurring on/between a provider's Medicare Opt Out List effective and 
end dates. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
psychotherapy provided on November 17, 2021, and December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental x-rays (D0274) provided December 22, 2021. 
 
You asked the Plan to pay for the dental x-rays. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the benefit for this service was exceeded. 
 
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, one set of dental x-rays is covered 
annually. The record shows this service was already covered. Therefore, we decided that the Plan does not have 
to pay for dental x-rays (D0274) provided December 22, 2021.
Appeal type: ER
Decision: Unfavorable

We decided the Plan does not have to pay for emergency room services billed to the enrollee for June 17, 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 this is a duplicate claim to a payment already made to the provider. Maximus overturned
the Plans denial for a lack of proof of payment in the case file. The Plan requested a reopen and provided
additional claim information. The Plans shows that this is an administrative denial for duplicate billing. The
records support one unit of 99285 was provided to the enrollee and approved and paid previously to this
provider. The second claim shows no documentation supporting additional services were provided beyond
what was previously paid.
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, the Plan has provided documentation to show this service was previously
paid. Medicare rules for coverage of the second claim submitted are not met. Therefore, we decided that the
Plan does not have to pay for emergency room services billed to the enrollee for June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740), a pontic (D6245), and a 
core buildup (D2950) provided on February 9 to February 22, 2022. 
 
You asked the Plan to pay for a porcelain/ceramic crown, a pontic, and a core buildup. You say that the 
services at issue were a medical necessity for you. The Plan denied your request. The Plan says rules for 
payment for dental services have not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental 
services up to a $1,000 annual maximum. 
 
We looked at the file and Medicare rules. The Plan has documented that you have met the $1,000 annual 
maximum. Based on this information, we decided that the Plan's rules for coverage of a porcelain/ceramic 
crown have not been met. Furthermore, though the Plan offers a dental benefit in excess of Medicare coverage, 
a pontic and a core buildup are not among the services covered under this benefit. Therefore, we decided that 
the Plan does not have to pay for a porcelain/ceramic crown (D2740), a pontic (D6245), and a core buildup 
(D2950) provided on February 9 to February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance for needle placement (77002) and 
moderate sedation services (99153) provided on August 9, 2021. 
 You asked the Plan to pay for fluoroscopic guidance for needle placement and moderate sedation services. You 
say that you have provided records to support the services at issue. The Plan denied your request. The Plan says 
rules for payment have not been met. 
 
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 77002 is an add-on code and has not been billed with an appropriate 
primary procedure code. Furthermore, code 99153 has a professional/technical component indicator of 3. This 
means that this code describes the technical component (i.e., staff and equipment costs) of selected diagnostic 
tests for which there is an associated code that describes the professional component of the diagnostic test only. 
Payment for the technical component of this code is included in the payment to the facility and is the 
responsibility of the facility to any vendor. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for fluoroscopic guidance for needle 
placement (77002) and moderate sedation services (99153) provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to waive the $135 cost share for a specialist visit (urologist) and outpatient
surgery provided on July 6, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this bill 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 overturned the Plans denial due to a lack of contract information in the file. The
Plan requested a reopen and provided the required contract information.
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 cost share for specialist services and outpatient surgery. You have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
cost share for a specialist visit (urologist) and outpatient surgery provided on July 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has complex medical needs 
that require ongoing care at an LTACH. The Plan denied your request. The Plan says the requirements for 
coverage have not been met. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral surgery services (D4263, D7210, D9222, D9223) 
provided on October 27, 2021. 
 
You asked the Plan to pay for oral surgery services. You say that these services were necessary. The Plan 
denied your request. The Plan says dental services are only covered when received from a licensed dental 
provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's contract says that 
you may see any licensed dental provider who accepts Medicare patients in the United States and has not opted 
out of Original Medicare. If you use a provider that has opted out of Medicare, you will not receive 
reimbursement. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from a 
provider who does not participate in Original Medicare are not covered under this benefit. We have confirmed 
that the provider in this case does not participate in the Medicare program. Therefore, we decided that the Plan 
does not have to pay for oral surgery services (D4263, D7210, D9222, D9223) provided on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay 50% for the root canals (D3320 x 2), non-intravenous conscious 
sedation (D9248), and inhalation of nitrous oxide (D9230) provided on December 6, 2021. 
 
You asked the Plan to pay 50% for the dental services. You say that you are aware this is a dental procedure. 
You say that you are aware your 2021 coverage does not include coverage for this service. You also say that 
your coverage does not listed as procedure code, but specifically provides a benefit of 50% of the cost of a root 
canal. The Plan denied your request. The Plan says the services you received are not listed as covered. The Plan 
also says that you were not enrolled in the optional supplemental dental rider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 50% f
or the root canals (D3320 x 2), non-intravenous conscious sedation (D9248), and inhalation of nitrous oxide 
(D9230) provided on December 6, 2021.