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

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided from 
September 26, 2022, to September 28, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were told to get 
these services from your doctors. 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 $90 
copayment for emergency services.  
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
outpatient hospital 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 an 
emergency room visit provided from September 26, 2022, to September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 15, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the service obtained 
by the member was rendered by a provider who is not under contract with the health Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on October 15, 2022, by an  
out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says Medicare coverage 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 states that the medical records do not show you met all of the criteria required for this
type of admission.
The Plan is correct in this case. 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. Based
on the medical records provided, you did not meet the required Medicare criteria for IRF admission, and it was
not expected that you would be able to participate in three hours of physical therapy per day five days a week.
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 provide coverage for acute inpatient rehabilitation facility
(IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for a second claim billed for April 13, 2022, under code 49083.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says this claim is a duplicate of a previously paid claim and therefore was correctly denied.
Maximus overturned the Plans denial for insufficient claim information in the case file. The Plan requested a
reopen and provided the required information.
The is correct in this case. The Plan must follow Medicare rules. The rules say that claims or claim lines that
have been determined to be exact duplicates of another claim or claim line are denied. Comparison of the two
claims shows these are exact duplicates. There is no evidence presented to support that the billed services were
provided twice on the same date. Based on this information, we decided that the Medicare rules for these
services were not met. Therefore, we decided that the Plan does not have to pay a second claim for services
provided to the enrollee on April 13, 2022 and billed under code 49083.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device coded 
as 22870 and 22869. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that you are requesting an appeal in response 
to a preauthorization denial for the posterior interspinous decompression spacer procedure to treat lumbar 
spinal stenosis with neurogenic claudication. The Plan denied your request. The Plan says this procedure is 
considered experimental and investigational as there is insufficient evidence of its safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Vertiflex Superion interspinous spacer device coded as 22870 and 22869.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing provided on December 17, 2021.
You asked the Plan to pay for the F1CDx testing. You say that you would like this claim reprocessed and approved for payment as the testing performed was medically necessary. The Plan denied your request. The Plan says that the specimen was collected during an outpatient encounter.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. 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, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing provided on December 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure coded as 64628 and 64629. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the injections are only lasting one 
week and the enrollee needs a longer lasting plan. The Plan denied your request. The Plan says this service is 
considered experimental and investigational as the is insufficient evidence to establish safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Intracept procedure coded as 64628 and 64629.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health services provided to the enrollee on May 5, 2022.
You asked the Plan to pre-approve the home health services. You say that you have a contract with the Plan. The Plan denied your request. The Plan says that the home health services were billed with the incorrect Type of Bill. Maximus overturned the Plan's denial. The Plan requested a reopening based on the fact the claim was submitted with the incorrect type of bill code. The claim was not filed with the correct type of bill code.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve the home health services provided to the enrollee on May 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure coded as 64628 and 64629. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says this procedure is unproven 
and not medically necessary due to insufficient evidence of safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Intracept procedure coded as 64628 and 64629.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair and accessories. You say that the requested 
items are medically necessary. The Plan denied your request. The Plan says that Medicare does not cover 
durable medical equipment in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
The records show that a Group 3 power wheelchair and accessories are being requested for use in a SNF or 
hospital. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and 
accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 13, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there is no authorization for this date of service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on July 13, 2022, by an out-of-network 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the clinic visits provided on October 31, 
2022, to November 1, 2022. 
 
You asked the Plan to waive the copayments for the clinic visits. You say that these visits were part of an 
inpatient hospital stay. 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 $35 
copayment for each specialist visit, including outpatient clinic visits.  
 
You have been asked to pay a $35 copayment for each outpatient clinic visit. You have been asked to pay a 
total of $70 for these specialist office visits ($35 copayment x 2 visits = $70). These items/services fall within 
the outpatient hospital 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 copayments for 
the outpatient clinic visits provided on October 31, 2022, to November 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed for date of service October 2, 
2021, to October 30, 2021. 
 You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 84520 is bundled into payment for code 80053. 
 
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 84520 
is a column II code to column I code 80053. This claim has not been billed with an appropriate modifier to 
bypass the edit. The other claim lines are being denied due to an OCE edit error on the claim lines.Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for the laboratory services billed for date of service October 2, 2021, to October 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device (22869, 
22870). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this procedure was initially approved with 
the other insurance carrier. The coverage changed and now the Plan will not honor the other carriers approval. 
The Plan denied your request. The Plan says this device is considered experimental and investigational as there 
is insufficient evidence in its safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Vertiflex Superion Interspinous device (22869, 22870).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81003 billed for date of service September 4, 
2022. 
 
You asked the Plan to pay for procedure code 81003. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 81003 is bundled into payment for code 80307. 
 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 81003 
is a column II code to column I code 80307. 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 81003 billed for date of service September 4, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on May 21, 2022, to May 25, 2022, 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 the claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does not support the billed code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with secondary diagnosis code J96.22, described as acute and chronic respiratory failure with hypercapnia. 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 inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does not support the billed code Our physician reviewer found there was no evidence of treatment consistent with acute and chronic respiratory failure with hypercapnia such as administration of oxygen 5L or more, provision of bilevel positive airway pressure (BiPAP) and/or mechanical ventilation to maintain adequate oxygenation at rest, unless the patient is on these therapies at home or they are provided solely for other reasons such as airway protection or work of breathing.

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 May 21, 2022, to May 25, 2022, at the Diagnosis Related Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel, 51 or more genes (81455) provided to the enrollee on January 11, 2022.
You asked the Plan to pay for the testing. You say that the test was ordered by the treating physician because the test results were needed to help determine the course of treatment for this enrollee. The Plan denied your request. The Plan says that this was not taken by the laboratory directly.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. 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, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel, 51 or more genes (81455) provided to the enrollee on January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing services (81455) provided to the enrollee on April 18, 2022.
You asked the Plan to pay for the laboratory testing services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the specimen was collected during an outpatient encounter.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. 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, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing services (81455) provided to the enrollee on April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve pulmonary surgery. You say that you feel the enrollee needs to have this 
surgery by you and your facility because you are specialized in this. The Plan denied your request. The Plan 
says the service can be provided by an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
pulmonary surgery to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from January 2, 2021 to 
January 4, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the initial 
claim was filed over a year from the date of the service. 
 
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 physician's services was not filed until September 21, 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 physician's services provided from January 2, 2021 to  
January 4, 2021.