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

 
We decided that the Plan does not have to waive the copayment for an outpatient facility colonoscopy on 
November 8, 2021. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that this was a routine colonoscopy, 
and that there should not be a copay. The Plan denied your request. The Plan says there is a $275 copay per 
visit, per provider, per day for surgery performed in an outpatient surgical center. 
 
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 $275 
copay for outpatient hospital services.  
 
You have been asked to pay a $275 copay for a colonoscopy. A colonoscopy falls within the Outpatient 
Hospital Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient facility 
colonoscopy on November 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on August 27, 
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 if there is no transport, it is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 27, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided to the enrollee on 
August 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine transportation trips received April 20, 2021, to May 
27, 2021 
 
You asked the Plan to pay for the additional trips. You say that this was needed for physical therapy visits or 
doctor visits. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
There were 24 one-way trips received between January 4, 2021 to April 15, 2021. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. 
Therefore, we decided that the Plan does not have to pay for routine transportation trips received April 20, 
2021, to May 27, 2021
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your rehabilitation needs are not complex enough to require 
coordinated care between therapy disciplines. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness, falls, urinary tract 
infection, and rhabdomyolysis. Your medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria 
for IRF 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 21, 
2021. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 76981. 
 
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 76981. 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 76705 billed for date of service January 21, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction of paravertebral facet joint nerves (also 
known as thermal facet joint RFA (CPT code(s): 64625 and 64636). 
 
You asked the Plan to pre-approve the services. You say that the enrollee is suffering from low back pain and 
their pain is causing issues with walking and sleeping. The Plan denied your request. The Plan says your 
request is not medically necessary because the enrollee's records show they do not have a second Median 
Branch Block injection available for review in the enrollee's records that were provided to the plan. 
 
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 services. Our physician reviewer found two separate sets of diagnostic MBBs which produced greater than 80% pain relief are required before 
RFA. Only one set has been performed. Therefore, at this point, the request is deemed not medically reasonable 
or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction of paravertebral facet joint nerves (also known as thermal facet joint RFA 
(CPT code(s): 64625 and 64636).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency services visit on February 20, 
2022. 
 
You asked the Plan to waive the copayment for emergency services visit. You say that you had serious shingles 
rash on Friday and by Sunday, you felt you had to go to the ER instead of waiting two more days to see your 
provider. It was not a pressing emergency, but you state you needed to get the medicine within the first 48 
hours or else it would not be effective. The Plan denied your request. The Plan says it was determined that you 
did receive an emergency room service rendered on 2/20/2022. Per your Evidence of Coverage, you pay $110 
for each covered emergency room visit. 
 
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 $110 for 
emergency services visit.  
 
 
 You have been asked to pay $110 for emergency services visit. Emergency services visit falls within the 
emergency services visit 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 emergency 
services visit on February 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on July 9, 2021. 
 You asked the Plan to pay for the services provided. You say that you enable physicians to deliver personalized 
cancer care. The Plan denied your request. The Plan says the services were not billed as required per coding 
regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnostic tests must be ordered by the physician 
who is treating the beneficiary, for a specific medical problem. 
 
We looked at the file and Medicare rules. The case file shows that the referring provided listed on the claim did 
not order the gene panel testing at issue. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the gene panel 
provided on July 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to reduce this cost share from $600 to $400.
You asked the Plan to reduce this cost share. You say that you do not believe this cost share was correct. The
Plan denied your request. The Plan says this cost share was charged based on the services provided and the
Plan contract agreement. Maximus overturned the Plans denial for a lack of documentation in the case file of
the first 20 covered days. The Plan requested a reopen and provided that documentation.
Based on the documentation provided, 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. The enrollee's contract with the Plan clearly says
that enrollees must pay $75 per day for days 21 to 100 of a skilled nursing facility.
The enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is
a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.
Therefore, we decided that the Plan does not have to pay for skilled nursing facility services provided to the
enrollee from August 1, 2021, to August 13, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C (Current Procedural Terminology (CPT) 
code J1561). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they do not have a record from the enrollee's prescriber that shows they have tried 
the preferred drug Privigen given by their doctor in the office, and it has not worked, or that the enrollee has 
medical reasons that prevent the enrollee from using it. 
 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 the medication. Our physician reviewer 
found the Plan requires a trial of drug Privigen and Hizentra before they will approve the requested drug. In 
this case, the enrollee has not tried and failed the required drug(s). The review has determined that the plans 
required drug(s) would not likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gamunex-C (Current Procedural Terminology (CPT) code J1561).
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your medical and therapy needs could be met in a skilled nursing unit. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for below the knee amputation = then received care in skilled nursing. You are now living at home and is ready to begin using a prosthetic.  
Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for drugs (J3490) billed to the enrollee for July 27, 2021.
You asked the Plan to pay this claim line. You say that this claim should be paid in full. The Plan denied your
request. The Plan says this claim line was billed for a code whose payment is bundled into another code billed.
Maximus overturned the Plans denial for insufficient claim information. The Plan requested a reopen and
provided additional documentation. The Plan says that according to the Outpatient Prospective Payment Status
(OPPS) Indicator, code J3490 has an indicator of N, which means that payment for this code is packaged into
payment for other services, including outliers. This means there is no separate payment for the 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 codes. In this case code J3490
cannot be paid separately as payment for this code is bundled into the facility claim. Therefore, we decided that
the Plan does not have to pay for drugs (J3490) billed to the enrollee for July 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received from August 9, 2021, to 
August 10, 2021. 
 
You asked the Plan to pay for the drugs. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
from August 9, 2021, to August 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 March 10, 
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 March 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (01215) provided to the enrollee on 
February 3, 2022. 
 
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 provider did not bill as required by Medicare coding regulations. 
 
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 01215 
is a column II code to column I code 01214. 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 anesthesia services (01215) provided to the enrollee on February 
3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 00940 provided on December 
9, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the services as billed are included in the 
primary procedure and separate payment will not be made. 
 
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 00940 is anesthesia for vaginal procedures (including 
biopsy of labia, vagina, cervix or endometrium); not otherwise specified. 
 
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 anesthesia services. Our reviewer says that the 
documentation does not support separate payment for the services billed. Our reviewer found that the submitted 
documentation was reviewed and only documents one procedure performed on this date of service. This claim 
is bundling into an additional claim for 141 units of primary procedure 00192. No medical records provided 
support separate payment for CPT 00940 as billed. 
 
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 anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services coded 00940 provided on December 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services provided to the enrollee on January 
14, 2022. 
 
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 patient was enrolled in hospice at this time. 
 
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 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 transportation services provided to the enrollee on January 
14, 2022.