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

We decided that the Plan does not have to waive the deductible for the office visit provided on February 8, 2022.
You asked the Plan to waive the deductible for the office visit. You say that you should have only been charged
a $5 copayment for the service. The Plan denied your request. The Plan says that the proper cost share was
applied for the charges that were billed.
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 there is a $750 deductible which applies to covered medical services.
The item or service you asked the Plan to waive the deductible for falls within the covered medical services
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750
deductible which applies to covered medical services. This cost sharing is a contractual obligation that had not
been met at the time the office visit was received on February 8, 2022. Therefore, we decided that the Plan does
not have to waive the deductible for the office visit provided on February 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the biopsy services provided on February 24, 2022.
You asked the Plan to pay for the biopsy services. You say that these services were medically necessary. The Plan denied your request. The Plan says that the provider needs to bill Medicaid.
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort.
Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services). These services qualified under the Medicaid coverage. The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to pay for the biopsy services provided on February 24, 2022.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit provided on February 4, 2022.
You asked the Plan to waive the copayment for the ER visit. You say that you shouldn't have to pay a copayment. The Plan denied your request. The Plan says that you are Medicaid eligible.
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible.
The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services). These services qualified under the Medicaid coverage. The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) visit provided on February 4, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on June 21, 2021.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan noted that this is an administrative determination for noncoverage and is not based on clinical criteria for medical necessity. The Plan states the claim did not include the required unique test identifier and there is no documentation of recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer.
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. In this case the claim is not supported by the medical records provided nor does the claim submitted have the required test identifier code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on June 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for outpatient mental health provided on June 
30, 2022. 
 
You asked the Plan to reduce the copayment for outpatient mental health. You say that you want the copayment 
reduced to $25. The Plan denied your request. The Plan says this cost sharing was charged 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 $40 
copayment for outpatient mental health care. 
 
You have been asked to pay a $40 copayment for outpatient mental health. This item/service falls within the 
outpatient mental health 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 reduce the copayment for outpatient 
mental health provided on June 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that this claim should be paid. The Plan denied your 
request. The Plan says these services are not covered by the Plan because the enrollee was enrolled in hospice 
at the time the services were rendered. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the lab services provided on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 3, 2021. 
Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service July 1, 2022. 
 
You asked the Plan to pay for procedure code 36000. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 36000 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable.  Based on this information, we decided that Medicare rules for coverage of procedure code 36000 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 36000 billed for date of 
service July 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4649 billed for date of service April 22, 
2022. 
 
You asked the Plan to pay for procedure code A4649. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code A4649 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code A4649 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4649 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4649 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4649 billed for date of service April 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 26, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you and 
the emergency medical services came to a mutual decision that you did not need to go to the hospital. You also 
say that you feel you should not be held responsible for this bill. The Plan denied your request. The Plan says 
your coverage does not provide for this ambulance service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 26, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on August 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRI provided on August 24, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for MRI. This item/service falls within the 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 copayment 
for MRI provided on August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93971 billed for date of service September 
20, 2022. 
 
You asked the Plan to pay for procedure code 93971. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 93971 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 93971 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 93971 billed for date of service September 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 22, 2022, 
to March 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 22, 2022. The NOA was not received by the Plan until February 
27, 2021. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from February 22, 2022, to March 23, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the physical or manipulative therapy (S8990) provided from May 11, 
2021, through January 25, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that they did not make a decision within the 
allowed time frame and therefore auto forwarded this case for review. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan contract states that a supplemental benefit is provided for 
unlimited visits each calendar year for non-Medicare covered additional services with a licensed chiropractor. 
However, the Plan contract does not clearly state what additional services are covered by this benefit. The Plan 
has not substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has 
to pay for the physical or manipulative therapy (S8990) provided from May 11, 2021, through January 25, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214), methylprednisolone acetate injection 
(J1030), dexamethasone sodium injection (J1100), ketorolac tromethamine injection (J1885), and the 
therapeutic, prophylactic, or diagnostic injection (96372) provided on March 28, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99214), methylprednisolone acetate injection (J1030), 
dexamethasone sodium injection (J1100), ketorolac tromethamine injection (J1885), and the therapeutic, 
prophylactic, or diagnostic injection (96372) provided on March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that you had a new billing system and staffing issues. 
The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until July 23, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on March 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on January 17, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
care provided on January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88360, 88381, & 88342 billed for 
date of service March 1, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88360, 88381, & 88342. You say that these services 
were medically necessary. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88360, 88381, 
& 88342. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88360, 88381, & 88342. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88360, 88381, & 88342 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88360, 88381, & 88342 billed for date of service March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0272) provided on October 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know that you had a limitation for 
x-rays. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 5, 2022. 
Therefore, we decided that the Plan does not have to pay for bitewings (D0272) provided on October 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on September 12, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that the compression stockings are medically 
necessary. The Plan denied your request. The Plan says the requested item is a non-covered item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
  Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99235 provided on August 30, 2022. 
 
You asked the Plan to pay for procedure code 99235. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 99235 is Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date. 
 
We find that CPT code 99235 is not supported in the medical record. Specifically, the record does not show 
that the patient was admitted and discharged on the same date. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99235 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99235 provided on August 30, 2022.