Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for code 99239 billed for date of service March 2, 2022.

You asked the Plan to pay for code 99239. You say that you have provided medical records to support
payment. The Plan denied your request. The Plan says the medical records do not support the billing of this
code.

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, code 99239 is a timed code,
meaning that the total number of minutes spent on the service must be documented in the medical record. The
medical records provided do not document the length of time that was spent on this service. Based on this
information, we decided that Medicare rules for coverage of code 99239 have not been met. Therefore, we
decided that the Plan does not have to pay for code 99239 billed for date of service March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on March 
17, 2022, by an OON provider. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that you are appealing the denial 
of the service rendered. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a subsequent nursing facility care visit provided 
on March 17, 2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from December 28, 
2020, to January 1, 2021, 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 you 
believe this claim has been underpaid. The Plan denied your request. The Plan says you have not provided 
medical records despite multiple requests for them.  Therefore, the DRG billed cannot be confirmed. 
 
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 inpatient hospital services provided 
from December 28, 2020, to January 1, 2021, at the Diagnosis Related Group (DRG) originally billed have 
been met. Specifically, you have provided no medical records for this hospitalization, despite the Plan 
requesting them multiple times.  Without medical records, we cannot determine if the billed DRG appropriately 
represents the services provided. Therefore, we decided that the Plan does not have to pay for inpatient hospital 
services provided from December 28, 2020, to January 1, 2021, at the Diagnosis Related Group (DRG) 
originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 70450-26 billed for date of service February 25, 2022. 
 
You asked the Plan to pay for code 70450-26. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
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. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 24, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 70450-26 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 70450-26 billed for date of service February 25, 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 enrollees nursing medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 hours over 
seven consecutive days. Therefore, the acute inpatient rehabilitation admission is not medically 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 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 cardiac risk assessment genetic screening testing (81225, 
81227, 81230, 81231, 81232, 81306, 81355, 81335, 81291, 0031U, 0032U, 0033U, 81238, 81479, 81407) 
provided on March 22, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you do not agree with the denial and are requesting 
reconsideration of payment for the denied claim. The Plan denied your request. The Plan says the services are 
not covered by Medicare. The Plan also says there is no documentation to show the enrollee was to undergo 
cardiovascular genetic testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. The documentation does not show that the testing at issue was 
ordered by the enrollees treating physician for a specific medical problem or treatment strategy. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing (81225, 81227, 
81230, 81231, 81232, 81306, 81355, 81335, 81291, 0031U, 0032U, 0033U, 81238, 81479, 81407) provided on 
March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture with flexible base (D5225). 
 
You asked the Plan to pre-approve the dental services. You say that you need the denture remade because you 
developed an allergic reaction to the metal wires in your first set. You say this caused your gums to swell and 
resulted in significant pain. 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 October 21, 2019. 
Therefore, we decided that the Plan does not have to pre-approve an upper partial denture with flexible base 
(D5225).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve venous angioplasty and stent placement. 
 
You asked the Plan to pre-approve venous angioplasty and stent placement. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that endovenous stenting is covered when specific criteria 
are met. 
 
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 venous angioplasty and stent 
placement. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
documentation does not meet guideline criteria for use of this therapy. In summary, there is insufficient 
documentation to support the medical necessity for the requested venous angiography and stent placement in 
this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of venous angioplasty and stent placement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve venous angioplasty and stent placement.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima. 
 
You asked the Plan to pre-approve Truxima. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Truxima. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
Rituxan or Riabni would likely be less effective, and/or would likely have adverse effects for the enrollee in 
this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular implant/abutment supported removable 
denture for edentulous arch (D6111) provided on April 13, 2022. 
 
You asked the Plan to pay for the mandibular implant/abutment supported removable denture. You say that you 
would like this denture to be approved for coverage. The Plan denied your request. The Plan says this service is 
not a covered benefit under your dental plan. 
 
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 the 
mandibular implant/abutment supported removable denture for edentulous arch (D6111) provided on April 13, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a panoramic 
radiographic imaging (D0330) provided by a participating provider on June 14, 2022. 
 
You asked the Plan to pay for a limited oral evaluation and a panoramic radiographic imaging. You say that 
you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendered dental 
services are not covered 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 a limited 
oral evaluation (D0140) and a panoramic radiographic imaging (D0330) provided by a participating provider 
on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided by an out-of-network provider 
on May 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 prophylaxis (D1110) provided by an out-of-network provider on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on May 3, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a comprehensive periodontal evaluation (D0180) is not covered by 
your routine 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 a 
comprehensive periodontal evaluation (D0180) provided on May 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged for inpatient care provided from
October 10, 2021, to October 13, 2021.
You asked the Plan to waive this copayment. You say that you were told you would not be charged the
copayment due to the treatment being for COVID-19. The Plan denied your request. The Plan says the waiving
of cost shares for COVID-19 treatment at an inpatient place of service ended on March 31, 2021.
Maximus overturned the Plans denial because documentation of when the waiving of copayment ending was
not included in the case file. The Plan requested a reopen and provided that documentation.
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 (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you must pay $175 per day for days 1 to 7 of an inpatient stay. The Plan provided
documentation that was sent out to enrollees and is also available online showing the copayment waiver for
COVID-19 ended officially March 31, 2021, prior to the dates in question. 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
charged for inpatient care provided from October 10, 2021, to October 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy with biopsy provided on 
May 13, 2022. 
 
You asked the Plan to waive the copayment for the endoscopy with biopsy. You say that you are appealing this 
cost-sharing. 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 $300 
copayment for surgery services provided at an ambulatory surgical center.  
 
 
   
You have been asked to pay the allowed amount of $212.29, which is less than the applicable copayment 
amount for the endoscopy with biopsy. The endoscopy with biopsy 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 the endoscopy with biopsy provided on May 
13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the denosumab injection provided on 
September 10, 2021. 
 
You asked the Plan to waive the cost share for the denosumab injection. You say that you have had these 
injections before and never had a coinsurance prior to this. 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 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay a 20% coinsurance for the denosumab injection for a total of $251.64 ($1,258.20 
allowed amount x 20% = $251.64). The denosumab injection falls within the Medicare Part B Prescription 
Drugs 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 cost share for the denosumab injection provided 
on September 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 11, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammography provided on 
May 12, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic mammography. You say that you are appealing 
this cost-sharing. 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 $75 
copayment for diagnostic procedures and tests.  
 
 
   
You have been asked to pay a $75 copayment for the diagnostic mammography. The diagnostic mammography 
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 the diagnostic mammography provided on May 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration of the denied 
authorization of inpatient rehabilitation facility admission. The Plan denied your request. The Plan says based 
on Medicare guidelines, the inpatient rehabilitation facility services you are requesting do not meet the 
requirements for approval. 
 
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 enrollee has multiple conditions and has hospital complications and may 
benefit from close medical supervision.  The evaluating therapists recommend home health with intermittent 
therapies thus the enrollee doesn't require intense therapy and doesn't meet the IRF criteria. 
 
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 IRF admission and services.