Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5253) purchased on  
July 27, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids must be 
purchased from the Plans select hearing aid provider. The benefit does not include or cover hearing aids that 
are purchased from an out-of-network provider. The hearing aids in this case were purchased from an out-of-
network provider. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing 
aids (V5253) purchased on July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on May 9, 
2022, and May 10, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says there should have been the reasonable expectation that the enrollee would 
improve post-hemodialysis and not require two midnights. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that while in the emergency department, the enrollee underwent emergent dialysis. 
However, a chest radiograph was negative for any acute processes and potassium was 6.9 with no 
electrocardiogram changes. The review indicates that the the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee on May 9, 2022, and May 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visit provided on July 22, 2022. 
 
You asked the Plan to waive the copayment for telehealth visit. You say that you are disputing the share cost. 
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 $35 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $35 copayment for telehealth visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits 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 telehealth visit provided on July 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to provide coverage for the implantation of an intrathecal pain pump.
You asked the Plan to provide coverage for this request. You say that approval of implantation of an intrathecal pain pump is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that based on the medical records provided, the enrollees pain was well controlled and therefore did not meet the required LCD criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for the implantation of an intrathecal pain pump. Based on the medical records provided, the methods being used to control pain were shown to be affective and the enrollee's medical condition had not changed in such a way that a pump of this type was the only alternative for treatment. Medicare rules for coverage of this request were not met. Therefore, we decided that the Plan does not have to provide coverage for the implantation of an intrathecal pain pump for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided the Plan does not have to provide coverage for six additional physical therapy visits for the
enrollee.
You asked the Plan to provide coverage for six additional physical therapy visits. You say that at the time of
the request, the additional visits were 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 is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for
medically necessary outpatient therapy. The medical records provided at the time of the appeal do not show
additional skilled services were required to restore or maintain function the enrollee's condition. Based on this
information, we decided that Medicare rules for coverage of six additional visits have not been met. Therefore,
we decided that the Plan does not have to provide coverage for six additional physical therapy visits for the
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for waive the cost share ($57) for a resin-based composite filling on tooth #1 (D2391) provided on April 21, 2022.
You asked the Plan to waive this cost share. You say that these dental services should be covered by the Plan. The Plan denied your request. The Plan says an alternative treatment was more appropriate in this case. Maximus overturned the Plans denial for a lack of medical records. The Plan requested a reopen and stated that this was a contractual issue and not a medical necessity issue.
The Plan is correct in this case. 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. Based on review of the services provided and your Plan contract agreement we find this claim processed correctly.
As white fillings on back teeth are considered cosmetic and there is no indication that you are unable to be provided with silver fillings when appropriate, the additional charge for a white filling was applied appropriately. Therefore, we decided that the Plan does not have to waive the cost share ($57) for a resin-based composite filling on tooth #1 (D2391) provided on April 21, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for any of these services billed for December 31, 2021.
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 the Medicare billing criteria were not met. Maximus partially overturned the Plans denial and directed the Plan to pay for code 97535-G0. The Plan requested a reopen and provided additional information. The Plan demonstrated that claim was submitted without a required modifier. A review of the PTP edit table found that while the Medicare coding rules indicate code 97535 is found under Column Two of the edit pair; code 97530 is found under Column One.
This PTP edit does have a "Deletion" data effective December 31, 2021. However, the services were performed prior to the code edit deletion was in effect, which would have been January 1, 2022.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the claim cannot be paid as billed due to the omission of a required modifier. Therefore, we decided that the Plan does not have to pay for the outpatient therapy provided on December 30, 2021, and December 31, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that at the time of the appeal, SNF 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.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services. The Maximus Physician Reviewer determined that there were multiple medical issues which would require supervision. The Plan requested a reopen and argues there is no medical record documentation to show there were any skilled nursing needs. The records show you are chronically bed bound and despite ongoing therapy in the hospital, you were only able to engage in edge of bed exercises. Based on the medical records provided, the Plan is correct in this case. The documentation does not sufficiently support that you required skilled nursing services or skilled therapy services on a daily basis on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (procedure code 99153) provided to the enrollee on August 26, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan states that Moderate sedation, codes 99151-99153, are services provided by the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports. They require the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. These codes are billed in increments of 15 minutes and are listed in addition to the primary service. Denials will occur for code 99153 when performed in a facility place of service (POS) setting. Medicare assigned this code a Professional/Technical Component (PCTC) indicator "3" effective for dates of service on or after January 1, 2017, per Change Request 9780 (Change Request 9780).
Technical components are not separately payable when performed by a physician in a facility setting because the facility has staff on hand to perform those services. The guidance states "code 99153 has no physician work associated with it and is therefore a technical component only code (PC/TC indicator 3). When billed in a facility setting it is not payable to the physician but may be paid to the facility. When billed in the office it is payable to the physician. Medicare assigned this code a Professional/Technical Component (PCT C) indicator "3" effective for dates of service on or after January 1, 2017. Technical components are not separately payable when performed by a physician in a facility setting because the facility has staff on hand to perform those services."
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 codes. In this case the Plan has demonstrated on reopen why code 99153 was billed in appropriately. Based on the records provided, this code cannot be billed separately. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for r moderate sedation services (procedure code 99153) provided to the enrollee on August 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for the lab services (81286, 81400, 81413, 81414, 81442 and 81479) provided to the enrollee on September 2, 2021.
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 the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file regarding the denial. The Plan requested a reopen and provided additional information. The Plan states the provider billed six different codes for a comprehensive cardiovascular NGS panel. The Medicare guidelines state providers should report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code.
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 the number of units billed. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services (81286, 81400, 81413, 81414, 81442 and 81479) provided to the enrollee on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious disease, pathogen-specific RNA, 4 targets, upper respiratory specimen (0241U) provided January 13, 2021.
You asked the Plan to pay this claim as billed. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial stating the service provided was medically necessary. The Plan requested a reopen and stated that this was not a medical necessity issue but a billing issue. The Plan stated the provider billed procedure code 0241U with a place of service (POS) code of 11 which is incorrect as this procedure may only be billed in places of service 20, 21, 23, or 81 (Urgent care, Inpatient hospital, Emergency room, or Independent Laboratory respectively). Additionally, the test was ordered by an inappropriate provider.
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 codes.
In this case, this claim cannot be paid as billed due to an inappropriate POS code reported on the claim and an inappropriate ordering or rendering provider. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for the infectious disease, pathogen-specific RNA, 4 targets, upper respiratory specimen (0241U) provided January 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 16, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 21, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for basic imaging of the foot provided on 
August 18, 2022. 
 
You asked the Plan to waive the copayment for basic imaging of the foot. You say that you thought this visit 
would be covered as a follow-up because it was the first visit after surgery. 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 $20 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $20 copayment for basic imaging of the foot. This item/service falls within the 
outpatient diagnostic test 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 basic 
imaging of the foot provided on August 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for endoscopy on June 06, 2022. 
 
You asked the Plan to waive the copayment for endoscopy. You say that you want to appeal the amount being 
charged. 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 $375 
copayment for each Medicare-covered service outpatient service. If you are having surgery in a hospital 
facility, you should check with your provider about whether you will be an inpatient or outpatient. Unless the 
provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-
sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered 
an outpatient. 
 
 
 
 
 You have been asked to pay a $375 copayment for endoscopy. This item/service 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 endoscopy on June 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist office visit provided on July 27, 
2022. 
 
You asked the Plan to waive the deductible for a specialist office visit. You say that you disagree with the 
deductible. 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 $1500 
deductible for Section 1.2 What is your plan deductible.  
 
You have been asked to pay a $1500 deductible for a specialist office visit. The total amount you are being 
asked to pay is $58.42 towards the deductible. This item/service falls within the Section 1.2 What is your plan 
deductible 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 deductible for a specialist office visit 
provided on July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a podiatry visit provided on August 9, 
2022. 
 
You asked the Plan to waive the copayment for a podiatry visit. You say that you disagree with the copayment. 
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 $25 
copayment for podiatry services.  
 
You have been asked to pay a $25 copayment for a podiatry visit. However, you are only being asked to pay 
$13.48 which is less than the required amount. This item/service falls within the podiatry 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 a podiatry visit provided on August 9, 2022.