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

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) billed for date 
of service March 25, 2022. 
 
You asked the Plan to pay for hospital discharge management. You say that this service was medically 
necessary and is supported in the medical record. The Plan denied your request. The Plan says this service is 
not supported as billed as the medical records do not support that more than 30 minutes of discharge care were 
provided on the date in question. 
 
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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the records provided do not 
indicate the amount of time spent providing discharge care services. Without this information, a time-based 
code such as 99239 cannot be verified. Based on this information, we decided that Medicare rules for coverage 
of hospital discharge management have not been met. Therefore, we decided that the Plan does not have to pay 
for hospital discharge day management (99239) billed for date of service March 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional payment for microsurgical technique 
described by code 69990. 
 
You asked the Plan to pre-approve the services. You say that the service is necessary. The Plan denied your 
request. The Plan says Medicare guidance says use of an operating microscope cannot be billed for separately 
for this type of surgery.  
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Medicare guidance says use of an 
operating microscope cannot be billed for separately for this type of surgery. Therefore, we decided that the 
Plan does not have to pre-approve additional payment for microsurgical technique described by code 69990.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 May 9, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #29 (D2950) provided on August 5, 
2022. 
 
You asked the Plan to pay for core build up. You say that this service should be covered as part of the crown 
procedure. The Plan denied your request. The Plan says core build up (D2950) is not covered by your 
supplemental dental benefits. 
 
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 core build 
up on tooth #29 (D2950) provided on August 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care for the surgical services 
(CPT code(s): 23472 and 23430). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical 
clearance to undergo this elective procedure. The Plan states the planned procedures listed under CPT codes 
23472 and 23430 are not listed on the CMS Inpatient Only List and the procedure is currently approved as an 
ambulatory procedure. The Plan states there is no documentation provided to support the expectation the 
enrollee will require a greater than 2 midnight stay. The Plan states if the enrollee experiences any peri- or 
post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review 
with updated clinical information. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the review indicates that the record did not show that the admitting 
physician reasonably expects that the enrollee's necessary hospital care will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care for the surgical services (CPT code(s): 
23472 and 23430).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services requested were medically 
necessary. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on June 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (CPT code E2300). 
 
You asked the Plan to pre-approve the power seat elevation system. You say that the item is necessary. The 
Plan denied your request. The Plan says the item is not covered by Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the power seat elevation system have not been met. The rules say 
that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they 
are not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve the power 
seat elevation system (CPT code E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3310). 
 
You asked the Plan to pre-approve the dental services. You say that your tooth's nerve is almost out and you are 
unable to eat solid food. You also say that your food and tongue go into the hole and you are in pain. The Plan 
denied your request. The Plan says this service is not covered by the Plan's dental benefits. 
 
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 pre-approve  
endodontic therapy (D3310).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on April 28, 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 procedure codes 34709 and 36571 are not supported. 
 
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 34709 is placement of extension prosthesis(es) distal to 
the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal 
aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer, including pre-procedure sizing and 
device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, 
and treatment zone angioplasty/stenting, when performed, per vessel treated (List separately in addition to code 
for primary procedure). The definition of code 36571 is insertion of peripherally inserted central venous access device, with subcutaneous port; age 5 years or older. 
 
We find that CPT codes 34709 and 36571 are not supported in the medical record. Specifically, there is no 
documentation of placement of an extension prosthesis(es) distal to the common iliac artery(ies) or proximal to 
the renal artery(ies) for endovascular repair to support code 34709. There is no documentation of insertion of a 
peripherally-inserted central venous access device to support code 36571. 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 the surgical services rendered on April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to be reimbursed for the total 
amount you have paid to the provider. 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 Plan paid 
$165 on April 7, 2022, and $835 on May 6, 2022, which is the $1,000 maximum benefit allowed. The record 
shows your benefit for the requested dental services was exhausted on date of service May 6, 2022. Therefore, 
we decided that the Plan does not have to pay for dental services provided on April 7, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77003 billed for date of service May 9, 2022. 
 You asked the Plan to pay for procedure code 77003. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says payment for code 77003 is 
bundled into payment for code 64493. 
 
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 77003 
is a column II code to column I code 64493. 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 77003 billed for date of service May 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy (code 97026-GP-59) provided on date of 
service January 12, 2022. 
 
You asked the Plan to pay for the infrared therapy.. You say that the medical records show the specific infrared 
device that was used and it was used on multiple parts of the body. The Plan denied your request. The Plan says 
this service is not covered. 
 The Plan must follow Medicare rules. Medicare rules say that infrared therapy is not covered for any 
indication. Therefore, we decided that the Plan does not have to pay for infrared therapy (code 97026-GP-59) 
provided on date of service January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and root cleaning, upper left and right 
quadrant. 
 
You asked the Plan to pre-approve dental services. You say that the services requested are medically necessary. 
The Plan denied your request. The Plan says the X-rays do not show these services are medically necessary. 
 
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 dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our physician reviewer 
found there is no medical necessity based on the provided x-rays for the requested procedures.  The provided x-
rays do not show any appreciable bone loss in the upper right or left quadrants. 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve deep gum and root cleaning, upper left and right quadrant.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on September 5, 2020, to
September 8, 2020, at the Diagnosis Related Group (DRG) originally billed.
You asked the Plan to pay for the inpatient hospital services at the DRG originally 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 for insufficient medical records in the file. The Plan requested a reopen
and provided the required records.
Our physician reviewer found Our Medical Director looked at the case file and the reopen request. At issue is
the principal diagnosis code assignment of A41.9 (Sepsis, unspecified organism). Maximus determined that the
plan had not made reasonable and diligent efforts to gather and forward. The medical records show the enrollee
was a then 86-year-old woman with a medical history that included stroke, diabetes, valvular heart disease, and
dementia. The enrollee presented to the hospital on September 5, 2022, with increasing weakness and
confusion. The History & Physical documents BP=167/68, pulse=105, RR=20, and temperature=99.5. The
enrollee appeared nontoxic and was in no distress. Laboratory studies were notable for WBC=11.9, Lactic
acid=1.1. The urinalysis suggested a urinary tract infection. A chest X-ray was negative. Blood cultures were
obtained. The impression included "Sepsis urinary tract infection." It is documented that the enrollee "is
hemodynamically stable." The Plan is correct in this case. The documentation does not sufficiently support a
principal diagnosis code of A41.9 (Sepsis, unspecified organism). The vital signs at the time of admission did
not fully meet systemic inflammatory response syndrome (SIRS) criteria.
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 on September 5, 2020, to September 8, 2020, at the Diagnosis Related
Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of tooth #2 and 27 (D7210) and an unlisted 
special service (99199) provided on April 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the requested items and services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the extraction of tooth #2 and 27 
(D7210) and an unlisted special service (99199) provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by a participating provider on 
May 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel like the Plan is trying to back out of 
paying. 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 May 4, 2022, and May 6, 
2022. Two crowns were provided on May 6, 2022; one crown was paid according to the EOC, the second 
crown was denied due to the benefit being exhausted. Therefore, we decided that the Plan does not have to pay 
for a crown (D2740) provided by a participating provider on May 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the portable oxygen concentrator 
provided on March 22, 2021. 
 
You asked the Plan to provide additional payment for a portable oxygen concentrator. You say that you were 
expecting a reimbursement of $160. 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 20% 
coinsurance for a portable oxygen concentrator.  
 
 
 
 
 You have been asked to pay $192.89 for a portable oxygen concentrator. The record indicates that the Plan has 
reimbursed you the Medicare allowed amount minus the cost share for the portable oxygen concentrator. This 
item/service 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 provide additional payment for the portable oxygen concentrator provided on March 
22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 28, 
2022. 
 You asked the Plan to pay for procedure code 88341. You say that separate procedures were done on separate 
specimens. The Plan denied your request. The Plan says payment for code 88341 is bundled into payment for 
code 88360. 
 
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 88341 is a column II code to column I code 88360. 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 88341 
billed for date of service February 28, 2022.