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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 19, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a radiological diagnostic test provided on 
March 31, 2022. 
 
You asked the Plan to waive the coinsurance for a radiological diagnostic test. You say that you were totally 
surprised by this bill, after already paying a $105 copayment. No one advised you that you might have a 
coinsurance charge for this. The Plan denied your request. The Plan says the cost share that was applied was 
correct. 
 
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 20% 
coinsurance for radiation (radium and isotope) therapy including technician materials and supplies. The 
allowed amount of this drug is $2813.52 resulting in a $562.70 coinsurance ($2813.52 x 20% = $562.70). 
 
You have been asked to pay a $562.70 coinsurance for a radiological diagnostic test. A radiological diagnostic 
test falls within Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 coinsurance for a radiological diagnostic test provided on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for practitioner services provided to the enrollee on August 20, 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 claim cannot be paid due to the taxonomy code. Maximus overturned the Plans
denial for insufficient explanation in the case file. The Plan requested a reopen and provided additional
information. The Plan stated that based on the Medicare NPI Registry, the servicing provider is listed under the
Taxonomy code definition of 3902xxxxxx which is listed as a Student in an Organized Health Care Education
or Training Program. The Plan spoke with providers staff employee who confirmed the reported NPI and stated
that the provider's credentials needed to be updated because she is an active physician. The staff employee
advised that she would begin the process to have the provider's credentials updated with Medicare, as she was
aware that at that time it was not up to date. However, no proof of credentials was ever received from the
provider prior to the closure of the appeal.
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 a valid taxonomy code. At the time the services
were provided and at the time the claim itself was submitted, the provider was not listed appropriately in the
NPI database and therefore not eligible to bill Medicare.
Neither the provider nor the staff employee spoken to by the Plan made any efforts to show this issue was
resolved so the claim could be paid. Therefore, we decided that the Plan does not have to pay for practitioner
services provided to the enrollee on August 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for emergency room services and outpatient imaging provided from January 2, 2022, to January 3, 2022.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost share was applied based on the services provided and the Plan contract agreement. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language.
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 a separate cost share for emergency room services and outpatient imaging services.
The Plan has provided documentation which shows the emergency room services and imaging services provided. 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 charged for emergency room services and outpatient imaging provided from January 2, 2022, to January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 17, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee's provider requested the testing 
to be done and you would like the claim reprocessed. The Plan denied your request. The Plan says the 
rendering and referring providers are both OON providers and there was no approved authorization. Also, the 
service rendered was not urgent or emergent. 
 
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 services provided on December 17, 
2021, 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 May 22, 
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 May 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) on 
April 04, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says the cost sharing you are being 
charged is correct. 
 
 
 
 
 
 
 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance of the total cost for each Medicare-covered durable medical equipment item. Covered items 
include, but are not limited to wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital beds 
ordered by a provider for use in the home, IV infusion pumps, speech generating devices, oxygen equipment, 
nebulizers, and walkers. The provider billed in the amount of $514.56 and the allowed amount is $12.60. 
$12.60 x 20% = $2.52. The provider also billed in the amount of $545 and the allowed amount is $137.50. 
$137.50 x 20% = $27.50. Billed in the amount of $693.50 and the allowed amount is $181.50. $181.50 x 20% 
= $36.30. Billed in the amount of $1,272.13 and the allowed amount is $324. $324 x 20% = $64.80. $27.50 + 
$36.30 + $64.80 = $128.60. $128.60 + $2.52 = $131.12. Therefore, results in the total cost sharing amount of 
$131.12. 
 
You have been asked to pay a 20% coinsurance for durable medical equipment (DME). Durable medical 
equipment (DME) falls within the Durable medical equipment (DME) and related supplies 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 coinsurance for durable medical equipment (DME) on April 04, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
February 18, 2020, to February 20, 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 DRG was updated.  
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 270 (OTHER MAJOR CARDIOVASCULAR 
PROCEDURES W MCC). 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 services. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the review has determined that the records did not support the principal code assignment of 
I95.81 - postprocedural hypotension. This is not an appropriate principal diagnosis code. The records did not 
support the secondary code assignment of E43 - unspecified severe protein calorie malnutrition. The records 
did not support the use of DRG 270 - OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC.  
 
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 to the enrollee from February 18, 2020, to February 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on February 24,
2021, coded as 25290.
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 the Medicare billing criteria are not met. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and provided additional information. The
Plan says that procedure codes 25609-RT, 24343-RT, and 24685-RT were approved and procedure codes
25290-RT and 77071 were denied as "Inclusive to another Billed Code."
Review was completed by a Board-Certified Orthopedic Surgeon. Procedure code 25290-RT, an open
tenotomy on a single flexor or extensor tendon of the forearm and/or wrist, for each tendon is documented in
the operative note submitted for review; however, this procedure is considered inclusive to CPT code 25609-
RT, an open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of
3 or more fragments; therefore, the code cannot be verified. According to (CPT) code definitions and guidance,
this claim denied for inappropriate billing of (CPT) code 25290-RT. Code 25290-RT is not supported in the
documentation.
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. The rules also say the
records provided must support the services billed. In this case, the records provided do not support the services
billed. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan
does not have to pay for surgical services provided to the enrollee on February 24, 2021, coded as 25290.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on April 05, 2021, to 
April 15, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 
correct. 
 
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 $185 
copayment for each day for days 1 to 5 for Medicare-covered hospital care. $0 copayment for additional 
Medicare-covered days. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other 
types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the 
hospital with a doctors order. The day before you are discharged is your last inpatient day. There were 10 
days. For days 1 to 5 a $185 copayment. $185 x 5 = $925. Therefore, results in the total cost sharing amount of 
$925.   You have been asked to pay a $185 copayment for days 1 to 5 of inpatient hospital stay. Inpatient hospital stay 
falls within the Inpatient hospital care 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 
inpatient hospital stay on April 05, 2021, to April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were independent before hospitalization and 
want to return to being independent. You say you are eager to participate in the aggressive rehabilitation. The 
Plan denied your request. The Plan says that the IRF care is not medically necessary, and the enrollee's needs 
can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the clinical documentation shows that you have multiple active comorbidities and hospital complications 
and will continue to require close medical supervision on an inpatient basis. You have a diagnosis of hypoxic 
encephalopathy which is an IRF compliant diagnosis. The record shows that the evaluating physical and 
occupational therapists state that you would benefit from and tolerate three hours of therapy per day thus IRF 
criteria have been met and is medically 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring, an 
electroencephalogram during coma or sleep, and neuromuscular junction testing monitoring provided to the 
enrollee on April 5, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says experimental and investigational services are not covered. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that continuous intraoperative neurophysiology monitoring, an 
EEG during coma or sleep, and neuromuscular junction testing monitoring were medically reasonable and necessary 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for continuous intraoperative neurophysiology monitoring, an electroencephalogram during coma 
or sleep, and neuromuscular junction testing monitoring provided to the enrollee on April 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 22, 2021, to February 10, 2021. 
 
You asked the Plan to pay for home health services. You say that you billed the claim correctly. The Plan 
denied your request. The Plan says you omitted to timely submit the RAP. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the Plan has 
attested that you did not submit a RAP for the services at issue until December 8, 2021. Therefore, we decided 
that the Plan does not have to pay for the home health services provided to the enrollee from January 22, 2021, 
to February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye exam on May 23, 2022. 
 
You asked the Plan to waive the copayment for eye exam. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 $40 
copayment for each Medicare-covered eye exam service. Covered services include outpatient physician 
services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related 
macular degeneration. Original Medicare doesnt cover routine eye exams (eye refractions) for 
eyeglasses/contacts. 
 
You have been asked to pay a $40 copayment for eye exam. Eye exams fall within the Vision Care 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 eye exam on May 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration of the denial of 
IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines, the inpatient 
rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
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 enrollee is at a level of function which does not require intensive rehabilitation. 
Our reviewer also found there are no complex nursing or rehabilitation needs.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (63036, 80053, 80061 and 84443) provided to the enrollee on October 14, 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 these services were already paid to the provider. Maximus overturned the Plans denial for a lack of claim information in the file to show previous payment. The Plan requested a reopen and provided the missing claim information.
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 provided documentation showing these services were previously paid. Therefore, we decided that the Plan does not have to pay for lab services (63036, 80053, 80061 and 84443) provided to the enrollee on October 14, 2021.