Persius/hicric huggingface dataset:
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 there is concern that the enrollee will not be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to the 
enrollee's reported level of pain and fatigue with therapy as well as some cognitive impairment. The medical 
records do not clarify that treatment at the skilled nursing facility level is not appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 presently receiving appropriate services in the short-term acute care 
setting. Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer 
to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility or a long-term care 
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 LTACH services.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the criteria for admission to an IRF have not been met. The Plan 
says that the enrollee's ongoing skilled therapy and skilled nursing needs can be provided at a lower level of 
care such as at a Skilled nursing Facility, on an intermittent basis at home with home health care, or in a long-
term care setting. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery and cardiogenic shock. The enrollee's medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does 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 this enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 pre-approve Jardiance. 
 
You asked the Plan to pre-approve Jardiance. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug 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 pre-approve Jardiance.  
 
Benefits for Jardiance may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94640 billed for date of service May 28, 
2022. 
 
You asked the Plan to pay for procedure code 94640. You say that this code is covered by the CMS fee 
schedule and was medically necessary. The Plan denied your request. The Plan says payment for code 94640 is 
bundled into payment for code 99283. 
 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 94640 
is a column II code to column I code 99283. 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 94640 billed for date of service May 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the gadobutrol injection provided on November 19, 2021.
You asked the Plan to waive the coinsurance for the gadobutrol injection. You say that you already paid the $110 copayment for the diagnostic magnetic resonance imaging (MRI), which is what you have paid for them in the past. 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% coinsurance for each Medicare-covered medical supply.
You have been asked to pay a 20% coinsurance for the gadobutrol injection. This item/service falls within the Medicare-covered medical supply 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 the gadobutrol injection provided on November 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 0184T-22 billed for date of service November 09, 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 are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct Medicare billing guidelines. The Plan submitted regulations that state "surgeries for which services performed are significantly greater than usually required may be billed with the "-22" modifier added to the CPT code for the procedure. Surgeries for which services performed are significantly less than usually required may be billed with the "-52" modifier. The biller must provide a concise statement about how the service differs from the usual; and an operative report with the claim. Modifier "-22" should only be reported with procedure codes that have a global period of 0, 10, or 90 days. There is no such restriction on the use of modifier "-52". The Plan states code 0184T has a global day's indicator as "XXX" for which the global concept does not apply. This means the modifier "22" should not be reported as per above Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when necessary, the appropriate modifier. In this case, the reopen has determined this claim was submitted with an inappropriate modifier. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 0184T-22 billed for date of service November 09, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation (90791) provided June 3, 
2022. 
 
You asked the Plan to pay for the psychiatric services. You say that you would like to appeal the decision to 
deny payment. You would like to continue your therapy sessions with this provider. The Plan denied your 
request. The Plan says Medicare does not consider Licensed Marriage and Family Therapists as an eligible 
provider type. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Also, on page 115 of the Plan's 2022 Evidence of Coverage, Licensed Mental Health Counselor is 
listed under Ineligible mental health and substance abuse providers in the Medical Benefits Chart. Therefore, 
we decided that the Plan does not have to pay for psychiatric diagnostic evaluation (90791) provided June 3, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for individual psychotherapy services (90832) provided March 
28, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that your physician provided medically 
necessary services to the enrollee in good faith. In consideration of the services rendered, you feel your doctor 
is entitled to reimbursement. The Plan denied your request. The Plan the services are not supported without 
required documentation.  
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for individual psychotherapy 
services (90832) provided March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for code A6504 for a compression burn garment provided on June 15, 
2022. 
 
You asked the Plan to pay for code A6504. You say that the medical records and the approved authorization 
support payment for the item in dispute. The Plan denied your request. The Plan says that the item in dispute is 
non-covered according to Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.  Specifically, the Plan has not substantiated their denial reason. The Plan says 
that Local Coverage Article (LCA): Surgical Dressings - Policy Article (A54563) states that the item/code in 
dispute is non-covered. This LCA does not state that. Code A6504 is coverable. In addition, you provided 
evidence that the Plan issued a prior authorization for a custom-made compression glove, including the wrist, 
worn to protect burn wounds. The Plan has not substantiated their denial reason that code A6504 is statutorily 
excluded from coverage by Medicare. Therefore, we decided that the Plan has to pay for code A6504 for a 
compression burn garment provided on June 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additional reimbursement for dental services provided on December 15, 2021.
You asked the Plan to pay additional reimbursement. You say that the Plan should provide more coverage for these services. The Plan denied your request. The Plan says this claim was processed based on the services provided and the Plan contract agreement. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information.
The Plan states that you are appealing the denial of payment for dental service D0140 (limited oral evaluation - problem focused) and the liability amount applied to service D0220 (intraoral - periapical first radiographic image) you received on December 15, 2021, out-of-network. The Plan states code D0140 denied for exceeding the benefit limitation. This code is covered once per year and provided documentation to show previous payment for these services for December 11, 2020.
The provider billed service D0220 in the amount of $65.00 for date of service December 15, 2021. The allowed amount for the service is $10.00. The plan paid the allowed amount of $10.00. On December 22, 2021. For out-of-network dental services you are responsible for all charges above what the plan pays ($65.00 - $10.00) which in this case is $55.
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 dental services have benefit limitations and out of network dental services have a higher cost share. You have been asked to pay the correct amount based on your contract with the Plan and the services billed by your provider. 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 pay additional reimbursement for dental services provided on December 15, 2021.
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 the enrollee had a below knee amputation and is 
trying to go to the rehabilitation. The Plan denied your request. The Plan says the stay is not medically 
necessary based on IRF criteria. 
 
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 there is not a reasonable expectation that this enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay further reimbursement for dental services provide on December 1, 2021, coded as D0220, D0140, D0230, and D2335.
You asked the Plan to pay further reimbursement for these services. You stated you only authorized the provider to fix a chipped tooth. You stated that no other services were authorized to be done by you and you should not be responsible for payment for unauthorized services.
The Plan stated that they previously paid for one intraoral x-ray for date of service December 1, 2021, and the Plan benefit does not include coverage for limited oral evaluation (problem focused). Maximus overturned the Plans denial for a lack of claim information in the file to show these types of services were previously paid. The Plan requested a reopen and provided additional information. The Plan stated that a payment of $221 was made to the provide, with a $110 member liability.
The Plan notes the Evidence of Coverage explains on page 86 that Intraoral X-rays (inside the mouth) are covered once per calendar year. The Plan submitted a claim to show two x-rays were billed, codes D0230 and D0220, by the provider. The Plan explained the Explanation of Benefits shows the $110 member liability has been applied to code D0140 (Limited Oral Evaluation) because this service is not a covered expense under the dental plan. Code D0220 (Periapical first radiographic image) denied because of the frequency limit.
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 were billing appropriately based on the contract limitations and the cost share agreement for dental services billed by the provider and dental services covered by the Plan. Therefore, we decided that the Plan does not have to pay further reimbursement for dental services provide on December 1, 2021, coded as D0220, D0140, D0230, and D2335.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 16, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -26 
modifier to allow for separate PC payment. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a GYN exam provided on January 26, 2022. 
 
You asked the Plan to pay for the GYN exam. You say that the services were recommended by the members 
primary care physician and it is recommended that patients over 65 have a physical examination every year to 
establish a personalized prevention. The Plan denied your request. The Plan says Medicare does cover cervical 
and vaginal cancer screenings when filed with the correct code. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. The file shows that Medicare and the Plan covers cervical and 
vaginal cancer screenings when filed with the correct code. The code billed is not the correct code. Based on 
this information, we decided that Medicare rules for coverage of the GYN exam have not been met. Therefore, 
we decided that the Plan does not have to pay for a GYN exam provided on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291, 99292) provided on July 24, 
2021. 
 
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 99291, & 99292 is not supported in the medical record. Specifically, while the 
documentation shows how much time was spent on the critical care services, the records do not document what 
services were provided as critical care. Based on this information, we decided that Medicare rules for coverage 
of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for 
critical care services (99291, 99292) provided on July 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided on March 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this service 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 the lab services have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. 
 
 
 
 
 
  
 Therefore, we decided that the Plan does not have to pay for lab services (83789) provided on March 23, 2022.