Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from October
21, 2020, to December 2, 2020.
You asked the Plan to pay for the whole of these services. We note the Plan indicates those portions of this
claim that could be were paid. You say that this claim should be paid. The Plan denied your request. The Plan
says the claim submitted was incomplete. Maximus overturned the Plans decision stating the denial reason was
incomplete. The Plan requested a reopen and provided additional explanation and information regarding their
decision. The Plan stated that an appropriate and complete itemized bill was not submitted by the provider. The
Plan states that without an itemized bill they are unable to validate all the charges reported.
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 submit claims with all
of the required elements set forth in the Medicare billing guidelines.
In this case, the provider failed to submit an appropriate itemized bill. Medicare rules for coverage of the whole
of these services. We note the Plan indicates those portions of this claim that could be were paid have not been
met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the
enrollee from October 21, 2020, to December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for a comprehensive oral evaluation provided on August 5, 2021.
You asked the Plan to pay for this service. The Plan denied your request. The Plan says this exam is covered
once every three years. Maximus overturned the Plans denial as documentation of the previous exam within the
last three years was not provided. The Plan requested a reopen and submitted the required documentation.
The Plan is correct in this case. Medicare generally does not cover dental services. 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 this service once every three years. The Plan provided documentation to show this service was rendered
on September 7, 2018. Payment for this service would not have been available until September 7, 2021.
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation provided on August 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prolonged service in the inpatient or observation setting 
(99357) provided on December 7, 2021. 
 
You asked the Plan to pay for prolonged service in the inpatient or observation setting. You say that these 
services are supported as billed. The Plan denied your request. The Plan says while 99223 and 99356 are 
supported, the records do not support 99357 based on the time documented for the enrollee's care. 
 
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 99357 is prolonged service in the inpatient or ovservation 
setting requiring unit/floor time beyond the usual service; each additional 30 minutes. 
 
We asked our coder 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 prolonged service in the inpatient or observation setting. Our 
reviewer says that this service is not supported as billed. Our reviewer found the documentation supports 100 minutes of patient care and was reported with an evaluation and management procedure code (99223) and 
additional prolonged service procedure code (99357). Time is not documented for each procedure code, but 
100 total minutes is noted for all services provided. For CPT 99223, the CPT code description states, 
"typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit". The definition of CPT 
code 99356 is prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the 
usual service; first hour. In this case, CPT 99357 cannot be verified, as 100 minutes documented does not meet 
time criteria for CPT 99223 and CPT 99356, since time was not reported for each individual procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prolonged service in the inpatient or observation setting have not been met. 
Therefore, we decided that the Plan does not have to pay for prolonged service in the inpatient or observation 
setting (99357) provided on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided January 18, 2022. 
 
You asked the Plan to pay for the dental cleaning. You say that you don't understand why this service is denied. 
The Plan denied your request. The Plan says you must submit your reimbursement request to the dental vendor 
for reimbursement review. 
 
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 
benefits through the Plan's third-party dental vendor. 
 
We looked at file and Medicare rules. In this case the reimbursement request was not submitted to the Plan's 
third-party dental vendor. The Plan provided documentation showing that they have advised that the claim 
must be submitted to the dental vendor for review. Based on this information, we decided that the Plan's rules 
for coverage of the dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay 
for the prophylaxis - adult (D1110) provided January 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a lymph node excision procedure 
performed on October 20, 2020. 
 
You asked the Plan to waive the copayment for the lymph node excision. You say that you are on social 
security and cannot afford the bill. The Plan denied your request. The Plan says you have been charged 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 $250 
copayment for each outpatient surgery or procedure.  
 
You have been asked to pay a $250 copayment for the lymph node excision. The lymph node excision falls 
within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 a lymph node 
excision procedure performed on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation does not support the rationale for this invasive imaging study. 
Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time cardiac 
catheterization would not be considered medically appropriate and necessary in this enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for venography (75827) and fluoroscopic guidance (77001) 
provided on October 22, 2021. 
 
You asked the Plan to pay for venography and fluoroscopic guidance. You say that these services should be 
covered. The Plan denied your request. The Plan says these services cannot be paid as billed. 
 
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 codes 
75827 and 77001 are column II codes to column I code 37248. 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 venography (75827) and fluoroscopic 
guidance (77001) provided on October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay a 50% coinsurance for prophylaxis. We decided that the Plan does not have 
to pay 100% for prophylaxis.  
 
You asked the Plan to pay for prophylaxis. You say that you would like the Plan to reconsider payment. The 
Plan says that the benefit limit for D1110 has already been met and exhausted. 
 
We decided that the Plan has to pay a 50% coinsurance for prophylaxis.  
 
The Plan follows Medicare rules. Medicare rules say that two D1110 are provided by an out-of-network 
provider per calendar year. Evidence was provided to show that one prophylaxis was provided on September 9, 2021.  
 
We also decided that the Plan does not have to pay 100% for prophylaxis. 
 
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 denied 
payment for prophylaxis. Therefore, we decided that the Plan does not have to pay 100% for prophylaxis. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology testing coded as 81292, 81206, and 
81301 provided July 23, 2021.  
You asked the Plan to pay for the laboratory services. You say that you are unable to obtain additional medical 
records from the referring provider. You ask for forwarding and processing of the information you have already 
provided. The Plan denied your request. The Plan says the service does not meet NCD/LCD criteria. 
 
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 find that CPT code 81292, 81206, and 81301 is not supported in the medical record. 
Specifically, Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. 
Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural 
service, so one CPT code must be submitted for the panel. Based on this information, we decided that Medicare 
rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for the molecular pathology testing coded as 81292, 81206, and 81301 provided July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) and complete lower 
denture (D5120) provided on February 17, 2022, by the out of network dentist. 
 
You asked the Plan to pay for the dental items. You say that you were not aware that the provider was out of 
network. You say that you are on a fixed income. You also say that you would like to be reimbursed. The Plan 
denied your request. The Plan says dental services received out of network are not covered. 
 
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 and dentures are listed as covered, 
dental items received out of network are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the complete upper denture (D5110) and complete lower denture (D5120) 
provided on February 17, 2022, by the out of network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 4, 
2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you only went for a COVID-
19 test. The Plan denied your request. The Plan says you have been charged 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 $50 
copayment for each urgent care facility visit.  
 
You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently Needed 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. Therefore, we decided that the Plan does not have to waive the copayment for an urgent 
care visit provided on January 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. 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 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. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on December 
13, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
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 until November 17, 2022. Therefore, we decided that the Plan does not 
have to pay for dental services provided by an opt-out provider on December 13, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) imaging with concurrently 
acquired computed tomography (CT) scan of the whole body. 
 
You asked the Plan to pre-approve a PET CT scan of the whole body. You say that the services are necessary. 
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET CT scan of the whole body. Our 
reviewer says that the services are medically necessary. Our physician reviewer found due to the widespread 
nature of multiple myeloma, PET/CT is the most thorough and comprehensive test available for this enrollee 
and is medically appropriate. 
 
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 PET CT scan of the whole body have been met. Therefore, we decided that 
the Plan has to pre-approve a positron emission tomography (PET) imaging with concurrently acquired 
computed tomography (CT) scan of the whole body.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse an additional amount for the limited oral evaluation 
(D0140) and periapical x-ray (D0220) provided on March 7, 2022, by an out of network dentist. 
 
You asked the Plan to reimburse an additional amount for the dental services. You say that you were not able to 
find a dentist locally. You say that this office advised they accepted your insurance. You say that you paid $103 
out of pocket on the date of service. You also say that had you known the provider was out of network you 
would have found a different one. The Plan denied your request. The Plan says out of network providers may 
bill you for any amount greater than what the plan pays the provider. 
 
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 and the services are listed as covered, 
out of network providers may bill you for any amount greater than what the plan pays the provider. 
Additionally, the Plan confirmed that the provider has already reimbursed the $27 overpayment. Therefore, we 
decided that the Plan does not have to reimburse an additional amount for the limited oral evaluation (D0140) 
and periapical x-ray (D0220) provided on March 7, 2022, by an out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions (D7311) 
provided on December 29, 2021. 
 
You asked the Plan to pay for the alveoloplasty. You say that your dentist deemed the extractions necessary. 
You also say that you cannot pay this bill. The Plan denied your request. The Plan says alveoloplasty 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 alveoloplasty is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the alveoloplasty in 
conjunction with extractions (D7311) provided on December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250), and resin-based 
composites (D2331 and D2392) provided by a participating provider on February 15, 2022. 
 
You asked the Plan to pay for the removal of residual tooth roots and resin-based composites. You say that you 
disagree with these charges. The Plan denied your request. The Plan says this claim has been processed 
correctly. 
 
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 Plan covers two removal 
resin-based composites per calendar year.  
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of resin-based composites have not been met for the remaining 10 fillings. The removal of residual 
tooth roots is not a covered dental benefit. Therefore, we decided that the Plan does not have to pay for the 
removal of residual tooth roots (D7250), and resin-based composites (D2331 and D2392) provided by a 
participating provider on February 15, 2022.