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

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on May 23, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you thought the ultrasound for your 
kidneys would be covered because you have a long-term chronic condition. You say you understood it to be 
considered wellness or diagnostic and have $0 copayment. The Plan denied your request. The Plan says the 
copayment applied 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 $100 
copayment for a Medicare-covered ultrasound.  
 
You have been asked to pay a $100 copayment for an ultrasound. An ultrasound 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 an ultrasound provided on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for r the anesthesia for a lower intestinal procedure (00811) and special anesthesia services (99100) provided on September 17, 2021.
You asked the Plan to pay for code 00811 or code 99100. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria for code 99100 were not met and code 00811 was handled separately. Maximus partially overturned the Plans denial stating the Plan did not provide an outcome for how code 00811 is being handled. The Plan requested a reopen and confirmed the required medical records they requested to review this code were submitted and code 00811 was sent for reopen and review at the Plan level.
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 code. Code 99100 has a status indicator of "B" in the Medicare Physician Fee Schedule. This means that payment for the service is bundled into payment for other services. Code 00811 is now under review by the Plan as the information they requested to substantiate payment was received.
Therefore, we decided that the Plan does not have to pay for the anesthesia for a lower intestinal procedure (00811) and special anesthesia services (99100) provided on September 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for hip surgery provided on December 21, 2020, out of the country.
You asked the Plan to pay for hip surgery provided out of the country. You say that this surgery was an emergency. The Plan denied your request. The Plan says out of country hip surgery is not considered to be urgent or emergent. Maximus overturned the Plans denial for not obtaining medical records. The Plan requested a reopen and stated that enrollees seeking coverage for bills out of the country have the burden of providing medical records and this surgery was not considered to be lifesaving surgery.
The Plan is correct in this case. Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that only emergency services are covered outside of the country. While we understand that the world was in the midst of COVID-19, hip surgery is not lifesaving surgery. You did not work with the Plan to determine coverage prior to having the surgery. Medicare records for services outside of the country are not the responsibility of the health Plan.
Based on this information, we decided that Medicare rules for coverage of non-emergent surgery out of the country have not been met. Therefore, we decided that the Plan does not have to pay for hip surgery provided on December 21, 2020, out of the country.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for surgical services coded as 51999 provided on August 3, 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 Medicare billed criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan states a National Correct Coding Initiative (NCCD) edit exists between open surgery codes for low anterior resection and repair of enter vesical fistula. This edit carries over to laparoscopic versions of these procedures. As a result, the requested procedure code would be considered inclusive to procedure code 44207-80. Therefore, the requested code 51999-80-59 cannot be verified.
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 code. In this case, code 51999 cannot be paid as billed due to its relationship to the primary code billed of 44207. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for surgical services coded as 51999 provided on August 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care.
You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, skilled nursing
facility services were medically necessary. The Plan denied your request. The Plan says Medicare coverage
criteria were not met. Maximus overturned the Plans denial for a lack of medical records in the file. The Plan
requested a reopen and submitted the required medical records.
The Plan is correct in this case. 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.
The medical records provided show an evaluation by physical therapy in the hospital notes you were nonambulatory
with moderate to maximal assistance for transfers. Your prior level of function was total assistance
for wheelchair mobility. You also required assistance for bed mobility and transfers. You have caregiver
assistance daily. Based on the records provided, your care would have been custodial in nature which is not
covered by Medicare. Therefore, we decided that the Plan does not have to provide coverage for skilled nursing
facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services billed to the enrollee for July 1, 2021.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says the Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan demonstrates that code 99153 is not separately payable when performed by a physician in a facility setting. The Plan notes the place of service listed on the claim image is 21 for Inpatient Hospital.
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, this code cannot be paid separately when billed under POS 21. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services billed to the enrollee for July 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for additional imaging services billed to the enrollee for date of service November 30, 2021.
You asked the Plan to pay this claim as billed. The Plan denied your request. The Plan says these services were previously paid. Maximus overturned the Plans denial stating the records provided support the services billed. The Plan requested a reopen and provided additional claim information. The Plan provided the claims to show that two units of abdominal x-rays were billed and previously paid by the Plan. The Plan provided the claim numbers and check numbers for payment made on January 5, 2022.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The Plan has provided documentation to show these services were billed a second time in error. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for additional imaging services billed to the enrollee for November 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient admission provided to the enrollee from September 1, 2020, to September 9, 2020.
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Plan no medical records were submitted to support the services billed. The Plan attempted to make partial payment based on the claim and what limited medical documentation they had. Maximus overturned the Plans denial. The Plan requested a reopen and reiterated that they agree with Maximus that without medical records the services provided cannot be fully reviewed. The Plan states records were requested but not received.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
There were insufficient medical records submitted to support the services and the diagnosis codes billed. We are satisfied that the Plan attempted to obtain records and received no response. Therefore, we decided that the Plan does not have to pay for inpatient admission provided to the enrollee from September 1, 2020, to September 9, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve L2 Kyphoplasty for the enrollee.
You asked the Plan to provide coverage for Kyphoplasty for the enrollee. You say that the service is medically necessary in treating the enrollee's pain due to the compression fracture at L2. The Plan denied your request. The Plan says that the records do not support that this service is medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 L2 Kyphoplasty. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has low back pain. On computed tomography scan a 20-25% compression fracture of L2 is reported. It is specifically stated that it is "mild acute". The request meets the criteria for a kyphoplasty and is deemed medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of K2 Kyphoplasty have been met.
Again, this reopen was for the sole purpose of clarifying the service requested and decided up on was for L2 Kyphoplasty and not T2 as previously stated.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the purchase of a transport chair on October 18, 2021.
You asked the Plan to pay for this purchase. You say that your physician told you to get a transport chair. The Plan denied your request. The Plan says you were approved for a transport chair in network that was to be rented but you chose to purchase the chair outright, which is not allowed for this type of equipment by Medicare. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that items such as mobility equipment like transport chairs are only available as capped rental items. Lump-sum purchase is not permitted. In this case, the Plan approved coverage for rental of a transport chair from a network provider. You chose not to rent a transport chair and purchased one out of network. You did not follow your Plans coverage rules when obtaining this equipment. Therefore, we decided that the Plan does not have to pay for the purchase of a transport chair on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network dental services provided on April 14, 2021.
You asked the Plan to pay for these services. You say that you thought this dentist was in network. The Plan
denied your request. The Plan says out of network dental services are not covered. Maximus overturned the
Plans decision administratively due to the incorrect Plan contract being submitted with the file. The Plan
requested a reopen and submitted the correct contract for review.
The Plan is correct in this case. Medicare 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. Though the Plan
offers a dental benefit in excess of Medicare coverage, the contract is clear that you must use network
providers. Therefore, we decided that the Plan does not have to pay for out of network dental services provided
on April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for dental services provided out of network on December 8, 2021.
You asked the Plan to pay for these services. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says this provider was not an eligible provider on the date of service. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan showed that the providers opt out status was not reinstated by Medicare until January 1, 2022. On December 8, 2021, the provider was in opt out status and was not an eligible dental provider per the Plan contract.
The Plan is correct in this case. Medicare does not cover dental services or allow Plans to cover services from opt out providers. The records show the provider was not eligible to provide dental services to Medicare enrollees on the date of service in question. Therefore, we decided that the Plan does not have to pay for dental services provided out of network on December 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF services were medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus administratively overturned the denial for a lack of medical records in the case file. The Plan requested a reopen and provided the additional medical records for review.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for inpatient rehabilitation facility (IRF) services. The medical records show the enrollee was a then 79-year-old man with a medical history that included hypertension and motion sickness. The enrollee was admitted to the hospital on April 29, 2022, with a fracture of the right femoral neck. A right hip arthroplasty was performed on April 30, 2022. The enrollee had no complications from the surgery. The enrollee was walking with the assistance physical therapy staff and a walker.
The documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not show the enrollee required an intensive inpatient rehabilitation therapy program. Medicare coverage criteria were not met at the time of the appeal. 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab service provided to the enrollee on September 17, 2021.
You asked the Plan to pay for this claim as billed. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan demonstrates that per Medicare Claims Processing Manual Chapter 12, Section 60 - Payment for Pathology Services: Physician hematology services include microscopic evaluation of bone marrow aspirations and biopsies. Medicare pays for the interpretation of an abnormal blood smear (code 85060) furnished to a hospital inpatient by a hospital physician or an independent laboratory. Payment may not be made if furnished to hospital outpatients or non-hospital patients. Medicare pays for the interpretation of an abnormal blood smear (code 85060) furnished to a hospital inpatient by a hospital physician or an independent laboratory. Review of the claim shows the provider billed with POS 22 which is for a outpatient hospital setting. No inpatient claim was billed for September 17, 2021.
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 place of service or POS code. In this case, the services billed are not eligible for payment in an outpatient setting. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for lab service provided to the enrollee on September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for retainer crowns (D6750) for teeth # 3 and 6, and pontic (D6240) for tooth # 4.
You asked the Plan to provide coverage for these dental services. You say that these dental services are medically necessary. The Plan denied your request. The Plan says the required dental criteria for this request are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan demonstrated that the Plans dental provider contract says that bridges will only be covered if no other teeth are missing in the same arch. The Plan provided dental x-rays show missing teeth that would prevent coverage for the requested dental services.
The Plan is correct in this case. Medicare does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not covered by the Plan when the area of treatment has missing teeth. Therefore, we decided that the Plan does not have to provide coverage for retainer crowns (D6750) for teeth # 3 and 6, and pontic (D6240) for tooth # 4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for nutrition counseling provided on March 14, 2022.
You asked the Plan to pay for this service. You say that these services should be applied to your benefit. The Plan denied your request. The Plan says the $1500 benefit was exhausted prior to the submission of this request. Maximus overturned the Plans denial because documentation of exhaustion of this benefit was not provided in the case file. The Plan requested a reopen and provided the required benefit information. This documentation shows the $1500 benefit was paid in full for 2022 prior to submission of this request. The claim for $10.05 cannot be paid due to exhaustion of this benefit.
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. Your contract with the Plan states there is a $1500 program. The documentation provided by the Plan shows this benefit was exhausted prior to this request. Therefore, we decided that the Plan does not have to pay for nutrition counseling provided on March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing coded as G0483, and specimen handling fee
coded as 99000 for services provided on September 28, 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 the Medicare billing criteria were not met for code 99000 and code G0483 is being
handled separately. Maximus partially overturned the Plans denial for not included the current status of the
claim for code G0483. The Plan requested a reopen and informed Maximus that the medical records they
requested for this code were now received and code G0483 was sent for a Plan reopen.
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 CPT code. Code 99000 has a
status indicator of B on the Physician Fee Schedule. This means that CPT code 99000 is not separately payable.
Code G0483 is being reprocessed at the Plan level. Therefore, we decided that the Plan does not have to pay for
drug testing coded as G0483, and the specimen handling fee coded as 99000 for services provided on
September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) and a prefabricated post 
and core in addition to crown (D2954) provided on October 1, 2020. 
 
You asked the Plan to pay for a porcelain/ceramic crown (D2740) and a prefabricated post and core in addition 
to crown (D2954). You say that the member was unaware that she had dental insurance and would like to be 
reimbursed for previous years claims when coverage was in effect. The Plan denied your request. The Plan says 
the supplemental dental services received October 1, 2020, are non-covered according to the 2020 EOC.  
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
porcelain/ceramic crown (D2740) and a prefabricated post and core in addition to crown (D2954) provided on 
October 1, 2020.