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

 
We decided that the Plan has to waive the copayment for telehealth services on March 15, 2022 
 
You asked the Plan to waive the copayment for telehealth services. You say that you should not be responsible 
for the copayment. The Plan denied your request. The Plan says that the cost share was 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 does not say in clear and accurate terms 
how much you should expect to pay for telehealth services rendered by a nurse practitioner.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $40 
copayment for telehealth services rendered by a nurse practitioner. The Plan contract does not clearly say how 
much enrollees must pay for telehealth services rendered by a nurse practitioner. This means that the Plan did 
not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to 
waive the copayment for telehealth services on March 15, 2022  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure codes G0483 and 99000) 
provided to the enrollee on November 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. 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 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. The rules also say that providers must report services correctly. Providers must report services with 
the appropriate procedure code. 
 
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, in terms of G0483, this claim was billed with the 
laboratory POS code. The records do not support that the sample was taken in a laboratory setting.  
 
Additionally, we find that procedure code 99000 has a status indicator of B on the Physician Fee Schedule. 
This means that procedure code 99000 is not separately payable. 
 
Therefore, we decided that the Plan does not have to pay for drug testing services (procedure codes G0483 and 
99000) provided to the enrollee on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on February 15, 2022, and 
February 18, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for chiropractic services. The Plan denied your request. The Plan says the enrollee 
received chiropractic services that were non-urgent/non-emergent and authorization was not obtained. 
 
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 chiropractic services provided on February 15, 
2022, and February 18, 2022, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care provided to the enrollee from October 19, 2021, 
to October 21, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support the services billed. 
 
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 the denied codes is: 
 
CPT 99233: 
 
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of 
these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs.  Usually, the patient is unstable or has developed a significant complication or a significant new problem. 
Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit 
 
CPT 99239: 
 
Hospital discharge day management; more than 30 minutes 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the review has determined that 
the records did not support that the enrollee received subsequent hospital care on 10/19/21. The patient was 
unstable without developing a significant new complication or problem. The medical decision making was not 
of high complexity. The records did not support that more than 30 minutes of hospital discharge day 
management was rendered on 10/21/21. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital care provided to the enrollee from October 19, 2021, to October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right heart catheterization for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are a number of other possible causes for the symptoms documented in the 
medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that in this case, the record indicates that the enrollee has persistent dyspnea in the setting of 
lower extremity edema. The record indicates that the enrollee has chronic kidney disease and is receiving 
amlodipine. The record does not indicate that no other evaluation has been performed. The record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve right heart catheterization for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no advantage in moving the enrollee from the current acute care 
hospital to the a long term acute care hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the short-term acute care hospital can provide for all of the enrollees present 
inpatient care needs and the enrollee is receiving an appropriate level of care in the present setting. The health 
plan has stated that continued care in the short-term acute care hospital will be covered as is medically 
necessary. Continued care in the short-term acute care hospital is appropriate until the patient is stable to 
transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a 
skilled nursing facility. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need LTACH services. The Plan 
denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 
currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroscopy with rotator cuff repair, acromioplasty, and 
labral repair. 
 
You asked the Plan to pre-approve the shoulder surgery. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 the shoulder surgery. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that detailed documentation is not evident regarding any left shoulder subjective and/or 
objective findings. Trial and failure of recent, reasonable and comprehensive, less invasive conservative care 
measures for the left shoulder is not evident. There are limited large-scale, long-term references showing the 
safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the shoulder surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve arthroscopy with rotator cuff repair, acromioplasty, and labral repair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for physical therapy visits provided from 
February 1, 2022, to February 24, 2022. 
 
You asked the Plan to waive the coinsurance for physical therapy visits. You say that you should not have to 
pay this coinsurance. The Plan denied your request. The Plan says the coinsurance applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Point-of-Service coverage. The allowed amount of these appointment is $776.02, resulting in a 
coinsurance amount of $155.19 ($776.02 x 20% = $155.19). 
 
You have been asked to pay a $155.19 coinsurance for physical therapy visits. Physical therapy visits fall 
within the Point-of-Service Coverage 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 coinsurance for 
physical therapy visits provided from February 1, 2022, to February 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70544 is bundled into payment for code 70551. 
 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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided from April 13, 2021, to
September 1, 2021, under the Medicare benefit.
You asked the Plan for to pay for these services. You say that you do not believe this bill is correct. The Plan
denied your request. The Plan says these services must be addressed under your Medicaid benefit. Maximus
overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says
that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included
documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually
eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid
may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal
care, and home- and community-based services). These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are
covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid
coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits.
Therefore, we decided that the Plan does not have to pay for these services under the Medicare benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on August 4, 2021. 
 
You asked the Plan to pay for the services provided. You say that this machine is required for your health. The 
Plan denied your request. The Plan says the device is only covered when rented. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the continuous positive airway pressure (CPAP) device and related supplies were purchased. This 
durable medical equipment has a -RR modifier, which means that it is to be rented. Based on this information, 
we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the 
Plan does not have to pay for the durable medical equipment provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional routine acupuncture visits. 
 
You asked the Plan to pre-approve 8 additional routine acupuncture visits. You say that you continue to require 
acupuncture services. The Plan denied your request. The Plan says this benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case. The Plan provides coverage for six routine acupuncture visits for any health 
condition.  
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you have exhausted the Plans benefit for six routine 
acupuncture visits. Therefore, we decided that the Plan does not have to pre-approve 8 additional routine 
acupuncture visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 19, 2021, under the Medicare benefit.
You asked the Plan for to pay for these services. You say that you do not believe this bill is correct. The Plan denied your request. The Plan says these services must be addressed under your Medicaid benefit. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort.
Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services). These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to pay for these services under the Medicare benefit.