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

 
We decided that the Plan does not have to pay for the interpretation of the ultrasound exam of the abdomen 
provided on January 10, 2022, billed with code 76705. 
 You asked the Plan to pay for the ultrasound interpretation. You say that this should be paid as there were 
multiple exams on this date of service. The Plan denied your request. The Plan says no appropriate modifier 
was reported. 
 
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 76705 
is a column II code to column I code 93976. 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 the interpretation of the ultrasound exam of the abdomen 
provided on January 10, 2022, billed with code 76705.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 sensor. 
 
You asked the Plan to pre-approve the sensor. You say that the sensor is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation does not show that you are using three (4) or 
more insulin shots per day or are on an insulin pump. Based on this information, we decided that Medicare 
rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve Dexcom G6 sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 1, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says despite 
multiple outreaches by the Health Plan, this provider has not submitted any clinical records to support the 
medical necessity of the services. 
 
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 an epidural injection provided on 
November 1, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 29, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided to the Health Plan are undated and unsigned. There is insufficient 
documentation of response to prior injections. 
 
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 an epidural injection provided on 
November 29, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation services provided to the enrollee on February 14, 
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 total units billed for this procedure exceed the allowed units. 
 
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 99220 is "Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and 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 problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit." 
 
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 an initial observation care service was 
performed on February 14, 2021. Therefore, any additional evaluation and management services performed on 
the same date of service, should be reported with an appropriate procedure code. 
 
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 observation services provided to the enrollee on February 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
December 16, 2021, to December 22, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $275 
copayment per day for days 1-5 of Inpatient hospital care.  
 
 
 You have been asked to pay a $1,375 copayment for 5 days of inpatient hospital care ($275 x 5 = $1,375). 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 inpatient hospital stay provided from December 16, 
2021, to December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME provided on April 22, 2021. 
 
You asked the Plan to pay for DME. The Plan denied your request. The Plan says that the Plan requires 
utilization of network providers when possible and available and requires authorization for certain services. No 
medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been 
documented.   
 
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 DME provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on December 6, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided to the Health Plan are undated and unsigned. There is insufficient 
documentation of response to prior injections. 
 
 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 an epidural injection provided on 
December 6, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on December 6, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the total knee arthroplasty (27447) provided on 
September 8, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan states that you must pay a $150 copayment for outpatient surgery provided at an 
outpatient hospital. 
 
The Plan says you must pay a $272.16 coinsurance for the outpatient surgery provided. Based on the Plan 
contract, however, you cannot be asked to pay more than a $150 copayment for outpatient surgery. 
Furthermore, the allowed amount for the surgery provided was $0 as stated in the Explanation of Benefits 
Statement processed on March 18, 2022; therefore, any cost sharing applied to this charge would be $0. 
Therefore, we decided that the Plan has to waive the coinsurance for the total knee arthroplasty (27447) 
provided on September 8, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from July 5, 2020, to
July 8, 2020.
You asked the Plan to pay for this claim as billed. You say that this claim should be paid as it was billed. The
Plan denied your request. The Plan says the diagnosis reported is not supported by the records provided.
Maximus overturned the Plans denial for a lack of medical records in the file. The Plan requested a reopen and
provided additional medical records.
Our Medical Director looked at the case file and the reopen request. At issue is a disagreement about DRG
assignment. Maximus overturned for a lack of medical records. The Plan requested a reopen and provided the
required medical record. The records show the enrollee is a 69-year-old man with a medical history that
included diabetes and hypertension, who presented to the hospital on July 5, 2020, with progressively
worsening shortness of breath and a productive cough. bilateral pneumonia. Blood pressure, heart rate, and
temperature were within unremarkable. SpO2 was 88%. The enrollee was admitted to the hospital with bilateral
pneumonia. Laboratory studies were notable for modest hyperglycemia. CBC was normal.
Our Medical Director has determined that the Plan is correct in this case. The additional documentation
submitted by the plan supports that the DRG of 871 (Septicemia or severe sepsis without mechanical
ventilation > 96 hours with major complication or comorbidity) was incorrectly coded.
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 care provided to the enrollee from July 5, 2020, to July 8, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on December 22, 2018.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says due to the enrollee's hospice status at the time of service, this claim should be submitted
to Original Medicare. Maximus overturned the Plans denial for lack of hospice documentation in the file. The
Plan requested a reopen and provided the required hospice status documentation.
The Plan is correct in this case. Medicare rules say that Original Medicare, not the Plan, is responsible for all
Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness.
The rules say that the Plan may direct the provider to bill Medicare directly for these services. The Plan has
provided documentation to show the enrollee was under the Medicare hospice benefit for the dates of service at
issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to
the enrollee on December 22, 2018.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged for emergency room and observation
services provided from May 14, 2021, to May 17, 2021.
You asked the Plan to waive this cost share. You say that you were admitted to the hospital and this cost share
should be waived. The Plan denied your request. The Plan says you were admitted to observation, which is still
considered and outpatient status. You were not admitted as an inpatient to the hospital. Maximus overturned
the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the contract correctly.
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. Your contract with the Plan clearly says that you must pay cost share for emergency
room services unless you are admitted to the hospital.
The medical records show you admitted from the emergency room to the observation level of care. You were
not admitted as an inpatient to the hospital. 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 emergency room
and observation services provided from May 14, 2021, to May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral radiographic imaging (D0220 and D0230), provided
by a participating provider on August 31, 2021.
You asked the Plan to pay for these services. You say that your Plan contract says these services are covered.
The Plan denied your request. The Plan says these services are only covered if you purchased the additional
supplemental dental benefit. Maximus overturned the Plans denial.
The Plan requested a reopen and provided additional enrollment documentation which shows you did not
purchase the supplemental dental coverage which would have included these services.
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.
Though the Plan offers a dental benefit more than Medicare coverage, the services provided are only covered if
you purchased the additional supplemental dental coverage. The enrollment documentation provided by the
Plan clearly shows you did not enrollee in the supplemental dental benefit for 2021. Therefore, we decided that
the Plan does not have to pay for intraoral radiographic imaging (D0220 and D0230), provided on August 31,2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of radiographic images (D0210), and a 
comprehensive oral evaluation (D0150) provided by a participating provider on January 26, 2022. 
 
You asked the Plan to pay for a complete series of radiographic images and a comprehensive oral evaluation. 
You say that you never received these services. The Plan denied your request. The Plan says the benefit limit 
for D0210 and D0150 have 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 Plan's coverage rules apply in this case. The Plan covers a complete 
series of radiographic images once every three years and a comprehensive oral evaluation once every five 
years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that these services were previously 
provided on July 23, 2020. Based on this information, we decided that the Plan's rules for coverage of a 
complete series of radiographic images and a comprehensive oral evaluation have not been met. Therefore, we 
decided that the Plan does not have to pay for a complete series of radiographic images (D0210), and a 
comprehensive oral evaluation (D0150) provided by a participating provider on January 26, 2022.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee from August 1,
2020, to August 31, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted
to Original Medicare. Maximus overturned the Plans denial for lack of documentation of hospice election in the
file. The Plan requested a reopen and confirmed the documentation had been sent and requested a review.
The Plan is correct in this case. Medicare rules say that Original Medicare, not the Plan, is responsible for all
Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness.
The rules say that the Plan may direct the provider to bill Medicare directly for these services. The
documentation provided by the Plan shows the enrollee was under the Medicare hospice benefit for the dates of
service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services
provided to the enrollee from August 1, 2020, to August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales tax for feeding tube bags/supplies provided on July 6, 2021. 
 
You asked the Plan to pay for sales tax. You say that these bags have been paid for in the past without need for 
authorization. The Plan denied your request. The Plan says the denial of payment for the sales tax charges is 
correct, because Medicare does not make separate payment for sales taxes. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not make any additional payment 
for sales taxes.  
 
We looked at the file and Medicare rules. As sales tax is factored into the base payment amount for these 
supplies, no separate payment for sales tax is made. Based on this information, we decided that Medicare rules 
for coverage of sales tax have not been met. Therefore, we decided that the Plan does not have to pay for sales 
tax for feeding tube bags/supplies provided on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the requested dental services for the enrollee.
You asked the Plan to provide coverage for an oral exam. You say that these dental services are medically
necessary. The Plan denied your request. The Plan says the enrollee had a comprehensive oral evaluation on
March 29, 2021. Maximus overturned the denial for a lack of claim information in the file to show this benefit
was exhausted. The Plan requested a reopen and provided the required claim information.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the benefit for the oral exam requested
had previously been exhausted. Therefore, we decided that the Plan does not have to provide coverage for the
requested dental services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition (CPT code(s): B4220 and B4224) 
provided from November 25, 2021, through December 1, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code(s) B4220 and B4224 are not supported in the medical record.  Code(s) B4224 (7 Units) 
and B4220 (7 units) remains not supported. The submitted medical records do not include documents to 
support that parenteral nutrition administration kit was ordered and delivered therefore, the billed service 
cannot be verified. It is noted that multiple attempts were made to contact the provider for additional 
information. 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 parenteral nutrition (CPT code(s): 
B4220 and B4224) provided from November 25, 2021, through December 1, 2021.