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

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
August 11, 2021. 
 
You asked the Plan to pay for hospital discharge day management (99239). You say that the correct codes were 
assigned, and no coding changes are required. You say that the medical records support the claim as originally 
billed and payment should be issued. The Plan denied your request. The Plan says the documentation does not 
support procedure code 99239. 
 
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 medical records do not 
support discharge management services of more than 30 minutes was performed, as required by the CPT code 
billed. Based on this information, we decided that Medicare rules for coverage of hospital discharge day 
management (99239) have not been met. Therefore, we decided that the Plan does not have to pay for hospital 
discharge day management (99239) provided on August 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says authorization denied because 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable and do not need a physician's close supervision three times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary. The Plan denied 
your request. The Plan says authorization denied because 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable and does not need a physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 10, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the laboratory services related to end-stage renal 
disease (ESRD) provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay further reimbursement for vision services provided on January 14, 2022.
You asked the Plan to pay further reimbursement for vision services and eyewear. The Plan denied your request. The Plan says this benefit has been paid correctly. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided additional information.
The Plan demonstrated the vision vendor billed $449.95 for eyeglasses. After the $150 benefit was applied, that left a balance of $299.95. You were then given a 20% store discount which reduced the balance owed to $239.96. In addition, it was determined that code V2797 denied correctly as this service is not eligible for discounts.
The Plan is correct in this case. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan provides a maximum of $150 for vision services and eyewear. The records show this balance was properly applied. Any balance remaining would be your financial responsibility. Therefore, we decided that the Plan does not have to pay further reimbursement for vision services provided on January 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets full IRF criteria. You also say that 
it has been determined by the enrollee's physicians that he requires intensive inpatient rehabilitation with daily 
physician management, 24 hour specialized rehabilitation nursing, and intensive therapies to optimize mobility 
and strengthening while ensuring the restoration of functional status for a safe and sustainable discharge. The 
Plan denied your request. The Plan says the member does not meet the Medicare criteria for admission to an 
IRF. The Plan also says that while the member will likely benefit from ongoing therapy to enhance 
rehabilitation potential, there is no evidence that this cannot safely be done at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. Our physician reviewer also 
found that medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane Injection Therapy. 
 
You asked the Plan to pre-approve Durolane Injection Therapy. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Durolane Injection Therapy. Our 
reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our 
physician reviewer found the enrollee has a diagnosis of bilateral primary osteoarthritis of the knees. The 
documentation does not support that the enrollee has tried and failed Orthovisc, and Synvisc or Synvisc One. 
The documentation does not support Orthovisc, and Synvisc or Synvisc One would likely be less effective, 
and/or would likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane Injection Therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Durolane Injection Therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 2, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the laboratory services related to end-stage renal 
disease (ESRD) provided on February 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation services provided on February 22, 2022. 
 
You asked the Plan to pay for the transportation services. 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 Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the transportation services provided on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2330), and a porcelain/ceramic 
crown (D2740) provided on March 7, 2022. 
 
You asked the Plan to pay for a resin-based composite (D2330), and a porcelain/ceramic crown (D2740). You 
say that sometimes the Plan informed you that the dentist was in-network and sometimes not in-network. The 
Plan denied your request. The Plan says this service is not covered when provided/performed by a non-network 
provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit when received from an out-of-network provider. Therefore, we decided 
that the Plan does not have to pay for a resin-based composite (D2330), and a porcelain/ceramic crown 
(D2740) provided on March 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an epidural injection provided on October 
29, 2021. 
 
You asked the Plan to waive the copayment for an epidural injection. You say that you should not be 
responsible for this cost share. The Plan denied your request. The Plan says the cost share has been applied 
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 $250 
copayment for epidural injection.  
 
You have been asked to pay $250 for an epidural injection. An epidural injection falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an epidural injection provided on October 29, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services with an out-of-network dentist. 
 
You asked the Plan to pre-approve dental services with an out-of-network dentist. You say that you have been 
seeing this dental provider for many years. The Plan denied your request. The Plan says services are covered 
with providers in the Plan network only. The Plan also says that there are dentists in the Plan network who are 
accepting new patients at this time. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services from an out-of-network 
provider are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve dental services with an out-of-network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and an 
immediate maxillary denture (D5130). 
 
You asked the Plan to pre-approve 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 items or services 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 items or services was exhausted on date of service June 25, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and an 
immediate maxillary denture (D5130).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay this claim as billed.
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 due to the change in hospice status during the treatment, this claim should have been split into two claims. One claim should have been submitted to Original Medicare for dates of service June 13, 2021, through June 30, 2021, and a separate claim should have been submitted to the Plan for dates of service July 1, 2021, to August 7, 2021. Maximus partially overturned the Plans decision, stating the Plan is partially responsible for payment of this claim. The Plan requested a reopen and stated that it agrees with Maximus that the Plan is responsible for dates of service from July 1, 2021, through August 7, 2021. However, hospice claims cannot be split and therefore the provider should have submitted two claims separate claims.
The Plan is correct in this case. 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 Plan has directed the provider to bill this claim appropriately due to change in hospice election during the dates of service billed. As this claim cannot be split, two separate claims should have been billed. Therefore, we decided that the Plan does not have to pay this claim as billed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
February 11, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you had hip surgery 
and had no other means of transportation. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $260 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $260 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance transportation provided on February 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that this is medically reasonable and necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's 
medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic.  
 
Benefits for Ozempic may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for crown - porcelain/ceramic (D2740) for tooth #3. 
 
You asked the Plan to pay for the crown. You say that the crown is medically necessary. The Plan denied your 
request. The Plan says that the x-rays show no evidence of decay and documentation does not show there is 
current restoration leaking that would require it to be replaced, or that a composite or amalgam restoration 
could not be used. 
 
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 the crown 
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 pay for the crown. Our reviewer says that a crown 
restoration is medically reasonable and necessary. Our physician reviewer found that a review of the 
documentation indicates that tooth #3 has a large restoration with severe marginal ditching and deep fissures. 
Our physician reviewer found that a crown restoration is medically reasonable and necessary to prevent 
fracture and provide adequate masticatory function. 
 
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 the crown have been met. Therefore, we decided that the Plan has to pay for 
crown - porcelain/ceramic (D2740) for tooth #3.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management; more than 30 
minutes, (99239) provided on October 16, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the services were provided 
to the enrollee in good faith. The Plan denied your request. The Plan says insufficient documentation was 
provided to corroborate the services to confirm that the Medicare coverage has been met. 
 
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. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the hospital discharge day 
management; more than 30 minutes, (99239) provided on October 16, 2021. have been met. Specifically, the 
file does not include documentation to support the billing of the service at issue. Therefore, we decided that the 
Plan does not have to pay for the hospital discharge day management; more than 30 minutes, (99239) provided 
on October 16, 2021.