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

 We decided that the Plan does not have to waive the copayment for the hospital outpatient clinic visits (G0463) 
with an in-network provider on March 10, 2021, and July 16, 2021. 
 You asked the Plan to waive the copayment for the outpatient hospital services. You say that the services were 
done during a doctor?s visit. You say you should not have to pay if a Medicare provider is billing. The Plan 
denied your request. The Plan says the cost-share was applied correctly. The procedures were received in an 
outpatient hospital setting. 
 
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 $275 
copayment for Outpatient Hospital Services.  
 
You have been asked to pay $473.59 in copayments for the hospital outpatient clinic visits. You received a hip 
injection (20610) on March 10, 2021, and an ultrasound (51798) and urinalysis (81003) on July 16, 2021, in 
outpatient hospital settings, thereby falling within the Outpatient Hospital Services benefit category. According 
to the Plan?s 2021 EOC, covered services include, but are not limited to: services provided in an emergency 
department or outpatient clinic and laboratory and diagnostic tests billed by the hospital. The copayment for 
date of service March 10, 2021, is $234.56. The copayment for date of service July 16, 2021, is $239.03.  
 
$234.56 + $239.03 = $473.59 
 
Since the total copayment is less than the required $550 ($275 per visit ? 2 = $550) copayment for the two 
outpatient hospital visits, 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 hospital outpatient clinic visits 
(G0463) with an in-network provider on March 10, 2021, and July 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a customized Zimmer Persona and ROSA system 
(C1776). 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the clinical value and effectiveness of the Zimmer Persona and ROSA system 
customized knee implant has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Zimmer Rosa 
knee system is experimental and not been shown to be more effective than conventional total knee surgery.  
 More research is needed. Our physician reviewer found that your condition does not meet criteria for coverage 
of these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a customized Zimmer Persona and ROSA system (C1776).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 21, 
2020. 
 
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 the services were not coded correctly. 
 
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 87798 is "Infectious agent detection by nucleic acid 
(DNA or RNA), not otherwise specified; amplified probe technique, each organism." 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, this code is not allowed with 
modifier CS. The other denied codes cannot be paid until this error is fixed. 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 laboratory services provided to the enrollee on December 21, 2020.
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 admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the enrollee requires skilled nursing services on a daily basis. The 
enrollee requires skilled therapy services; however, not on a daily basis. This enrollee does not require the 
services on an inpatient basis, only 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 admission to a SNF 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the replacement straps for an orthosis provided on April 17, 2021. 
 
You asked the Plan to pay for the replacement straps. You say that this should be paid as the straps are 
necessary. The Plan denied your request. The Plan says that this code has a status indicator of A, meaning that 
there is no separate Ambulator Payment Classification (APC) payment for this code. 
 
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. The Plan has failed to provide a valid denial rationale to support non-payment 
for this claim. The Plan's denial rationale is simply that the code is not payable per the Outpatient Prospective 
Payment System (OPPS). While it is true that this is not payable per the OPPS, this payment system is used 
only for institutional outpatient hospital claims. This was a professional claim from a Durable Medical 
Equipment, Prosthetics, and Orthotics (DMEPOS) supplier. This is an active code in the DMEPOS fee 
schedule. Without a valid rationale, we find that the denial of this code is not supported. Therefore, we decided 
that the Plan has to pay for the replacement straps for an orthosis provided on April 17, 2021.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay and additional amount for the inpatient care provided from May 
23, 2021, to May 28, 2021. 
 
You asked the Plan to pay and additional amount for the inpatient care. You say that the diagnosis was 
supported. The Plan denied your request. The Plan says the documentation does not support the billing of 
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code, J96.21, acute 
and chronic respiratory failure. 
 
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 ICD-10-CM code, J96.21, acute and chronic 
respiratory failure. 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 and additional amount for the 
inpatient care. Our physician reviewer found the documentation was inconsistent/unclear regarding a diagnosis 
of acute respiratory failure. The reviewer found that the supporting medical record documentation was not 
found within the record. Although the provider documented acute respiratory failure, reasonable support within 
the health record must be present for that diagnosis. Therefore, the reviewer found that the provided 
documentation did not support the billing the secondary diagnosis of ICD-10-CM code, J96.21 acute and 
chronic respiratory failure.  
 
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 
and additional amount for the inpatient care provided from May 23, 2021, to May 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health services, or home with outpatient therapy. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for respiratory failure and atrial fibrillation with rapid ventricular response. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the SNF visit provided from March 6, 
2021, to March 26, 2021. 
 
 
 You asked the Plan to waive the copayment for the SNF care. You say that you were told by the admission 
coordinator that the services were covered, and that no copayment would be assessed for the first 20 days. 
 The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount. 
 
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 $0 
copayment for each day for days 1 to 20 and a $184 copayment each day for days 21 to 53.  
 
You have been asked to pay a $2,944 copayment for the SNF care. The SNF care falls within the ?Skilled 
Nursing Facility (SNF) Care? benefit category. The record shows you received SNF services at a previous 
facility within the same benefit period. See chart below. 
 
Dates of Service Service SNF Days Copayment Day Count Member 
Liability 
December 7, 2020, 
to December 23, 
2020 
SNF care 1-16 $0 16 $0 
March 6, 2021, to 
March 9, 2021 
SNF care 16-20 $0 4 $0 
March 10, 2021, to 
March 26, 2021 
SNF care 21-37 $184 16 $2,9444 
Total     $2,9444 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the SNF visit provided from March 6, 2021, to March 26, 
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 not being admitted will jeopardize your 
ability to regain maximum function. The Plan denied your request. The Plan says that your records show you 
do not have a condition complex enough to require more than 25 days of continued inpatient care including 
daily doctor visits and specialized nursing 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. You are 
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. Our physician reviewer found 
that your condition does not meet Medicare criteria for LTACH services. 
 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99215) 
rendered on May 19, 2021. 
 
You asked the Plan to waive the copayment for an office visit with a specialist. You say that you tried to pay 
the copayment at the time of the appointment, but you were told by the provider's office that you did not have a 
copayment. You also say that you now have received a bill for the copayment from the provider's office. You 
also say that you should not have to pay this copayment, because you tried to pay it at the time of your 
appointment, and you cannot afford to pay it at this time. The Plan denied your request. The Plan says you were 
charged the correct copayment amount. 
 
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 $30 
copayment for each specialist visit for Medicare-covered benefits.  
 
You have been asked to pay a $30 copayment for an office visit with a specialist. 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 an office visit with a specialist (99215) rendered on May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on July 1, 2021. 
 
You asked the Plan to pay for the dental service. You say that you had to pay $2,000 out of pocket for this. You 
say that you had to borrow money to pay for this. You also say that you should not have to pay for this. The 
Plan denied your request. The Plan says bone replacement graft for ridge preservation is not listed as a covered 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the bone replacement graft for ridge preservation is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the bone replacement graft for ridge preservation (D7953) provided on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
February 25, 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 the enrollee did not have prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network physician services provided to the 
enrollee on February 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from April 16, 2021, to May 5, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the radiologist 
damaged your kidney, so you should not be responsible for this bill. The Plan denied your request. The Plan 
says you were charged this copayment 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 $175 
copayment per day for days 1-7, and a $0 copayment per day for days 8-90 for inpatient hospital services.  
 
Records show that you were in the hospital for 20 days.  You have been asked to pay a $175 copayment for 
each of the first 7 days of your stay, for a total of $1225. This copayment applies regardless of the reason for 
the inpatient services. 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 inpatient hospital services you 
received from April 16, 2021, to May 5, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for physician's services for an Echocardiography provided on 
May 24, 2021. 
 
You asked the Plan to pay for physician's services for an Echocardiography. You say that you were advised that 
none of the procedures would require precertification. The Plan denied your request. 
 
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. The Plan has not provided us with the Plan?s rules to support denial for these 
services. Therefore, we decided that the Plan has to pay for physician's services for an Echocardiography 
provided on May 24, 2021.  
 
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: Favorable

We decided that the Plan has to waive the copayment for an office visit with a specialist (99213) rendered on 
June 30, 2021. 
 
You asked the Plan to waive the copayment for an office visit with a specialist. You say that there should not 
be any charges for an office visit with a specialist, because you did not see a doctor at the hospital. You also  
say that you were sent to the facility by your primary care doctor for an x-ray. You also say that all the hospital 
did was x-ray your wrist. The Plan denied your request. The Plan says that you were charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for each primary care doctor office visit for 
Medicare-covered services.  
 
The Plan says you must pay a $45 copayment for an office visit specialist. Based on the Plan contract, 
however, you cannot be asked to pay more than a $0 copayment for each primary care doctor office visit for 
Medicare-covered services. The record does not show that an office visit with a specialist was rendered. 
Therefore, we decided that the Plan has to waive the copayment for an office visit with a specialist (99213) 
rendered on June 30, 2021.  
 
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.