Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 
14, 2021, to November 15, 2021. 
 
You asked the Plan to pay for inpatient care. You say that the inpatient admission was appropriate. You also 
say that it should have been paid in accordance with Center for Medicare and Medicaid (CMS) two midnight 
rule. The Plan denied your request. The Plan says there was no documentation provided to support that the 
services were medically necessary. 
 
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 inpatient care have been met. 
Specifically, the file does not include medical records to support the medical necessity of the inpatient 
admission. The record shows that the Plan made multiple requests for medical records, but nothing was 
received. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided 
from November 14, 2021, to November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart Implantable Pulse Generator. 
 
You asked the Plan to pre-approve the Optimizer Smart Implantable Pulse Generator. You say that the 
requested Optimizer Smart Implantable Pulse Generator is medically necessary. The Plan denied your request. 
The Plan says the requested Optimizer Smart Implantable Pulse Generator is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Optimizer Smart Implantable Pulse 
Generator. Our reviewer says that the requested Optimizer Smart Implantable Pulse Generator is not medically 
necessary. Our physician reviewer found an exhaustive review of the current medical literature pertaining to 
the cardiac contractility modulation (CCM) system confirms multiple observational studies suggesting clinical 
benefit from CCM. Several randomized clinical trials of CCM versus control have also been reported, along 
with meta-analysis pooling the data from multiple studies, with CCM providing meaningful improvement in 
quality-of-life scores and objective functional capacity. While the clinical studies led to FDA approval in 2019, 
CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, 
double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, I would not consider the CCM system 
to be medically necessary in this 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 Optimizer Smart Implantable Pulse Generator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Optimizer Smart Implantable Pulse Generator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing services provided on August 3, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory drug testing services. You say that services were rendered in good 
faith and were medically necessary. The Plan denied your request. The Plan says the services were provided by 
an out of network provider and there was no authorization on file for the services provided. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory drug testing services provided on 
August 3, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 25, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the member 
was enrolled in hospice on this date of service. 
 
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 physician's services provided on January 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) stay from 
April 1, 2022, through April 21, 2022. 
 
You asked the Plan to waive the copayment for SNF stay. You say that the enrollee should not be financially 
responsible for the additional time 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). The enrollees contract with the Plan clearly says that enrollees 
must pay days 1-20 $0 copayment per day, per admission and days 21-100 $160 copayment per day, per 
admission.  
 
  The enrollee has been asked to pay $1,120 copayment for SNF stay. The SNF stay started on March 25, 2022, 
through April 21, 2022, therefore the copayment is applied correctly. This SNF stay falls within the Skilled 
nursing facility (SNF) care benefit category. This means that 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 waive the copayment for 
skilled nursing facility (SNF) stay from April 1, 2022, through April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the dental services received on 
September 20, 2022. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you want the Plan to pay 
for the services. The Plan denied your request. The Plan says your benefit for the requested item or service has 
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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 20, 2022. 
Therefore, we decided that the Plan does not have to pay an additional amount for the dental services received 
on September 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from July 1, 
2022 to July 30, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled or therapist need. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that no required skilled nursing or skilled therapy services were identified. It was not 
medically reasonable or necessary to provide skilled services on a daily basis. The services were not required 
on an inpatient basis in the 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 pay for skilled nursing facility (SNF) care provided from July 1, 2022 to July 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit with physical therapy provided on 
August 09, 2022. 
 
You asked the Plan to pay for a home health visit with physical therapy. You say that this was medically 
necessary and should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home health visit with 
physical therapy provided on August 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
August 15, 2022. 
 
You asked the Plan to pay for the evaluation. You say that the services D0150 and D0140 are significantly 
different and the claim for D0150 should be accepted. The Plan denied your request. The Plan says your benefit 
for the requested item or service has 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 28, 2022. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on August 
15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management injections provided on October 18, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for pain management injections. You say that the services provided were medically 
necessary, and the records attached support these services. The Plan denied your request. The Plan says 
services can be obtained from an in-network provider, and the services were not authorized in advanced. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for pain management injections provided on October 
18, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for methadone weekly bundle treatment provided on May 01, 
2022, to May 31, 2022. 
 
You asked the Plan to pay for methadone weekly bundle treatment. You say that you do not understand the 
denial for services rendered because you have been seeing the same provider for years. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for methadone weekly 
bundle treatment provided on May 01, 2022, to May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection and a specialist office visit 
provided on August 11, 2022. 
 
You asked the Plan to waive the copayment for an injection and a specialist office visit. You say that you 
disagree with the cost share. 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 and a $45 copayment for Medicare Part B prescription drugs and physician/practitioner 
services/specialist office visit.  
 
You have been asked to pay a 20% coinsurance an injection and a $45 copayment for and a specialist office 
visit. The total allowed amount for the injection is $11.35. You are being asked to pay $1.18 for the injection 
($11.35 x 20% = $1.18). The total amount you are being asked to pay is $46.18 ($45 + $1.18= $46.18). 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 injection and a specialist office visit provided on August 
11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on August 03, 2022. 
 
You asked the Plan to pay for drug testing. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for drug testing provided on 
August 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy to be provided by an OON provider. 
 
You asked the Plan to pre-approve the massage therapy. You say that you would like approval for an out-of-
network provider that is closer to you. The Plan denied your request. The Plan says your needs can be met with 
in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
massage therapy to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 provided on June 9, 2022. 
 
You asked the Plan to pay for procedure code 99153. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of 
service code of 24. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical 
Component only code. Therefore, we decided that the Plan does not have to pay for procedure code 99153 
provided on June 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurology services (procedure codes 95886, 95908, 95937) 
provided to the enrollee on July 8, 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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 95886: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three 
or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 
 
 CPT 95908: 
 
Nerve conduction studies; 3-4 studies 
 
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support that 
CPT 95908 was rendered in this case. Rather, the patient underwent triggered electromyography (EMG) testing 
during surgery to evaluate pedicle screw placement. This is distinct from the performance of a nerve 
conduction study which is a separate test. The standard coding has always been to bill this under an EMG code. 
Therefore, as a nerve conduction study was not done, the coding is not supported. As for CPT 95908, as the 
nerve conduction study was not done, use of this code would not be appropriate. In terms of CPT 95937, the 
enrollee only underwent train of four testing, which for coding standards is inherent to performance of the 
EMG. There is no formal testing of the neuromuscular junction to look for a medical condition - which is what 
CPT 95937 reflects. 
 
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 neurology services (procedure codes 95886, 95908, 95937) provided to the enrollee on July 8, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the physical therapy (PT) services 
provided on April 22, 2022. 
 
You asked the Plan to waive the coinsurance for the physical therapy (PT) services. You say that your 
maximum out-of-pocket (MOOP) expenses had been met. 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 20% 
coinsurance for outpatient rehabilitation services. 
 
You have been asked to pay 20% coinsurance for the physical therapy (PT) services. This item/service falls 
within the outpatient rehabilitation 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. Please note that at the time the claim was processed, your MOOP had not 
been met. Amounts are applied to the MOOP in the order the claims are received and processed by the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the physical therapy (PT) 
services provided on April 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT scan) provided 
on May 31, 2022. 
 
You asked the Plan to waive the copayment for computed tomography (CT scan). You say that this should be 
covered. 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 $75 
copayment for Radiological diagnostic services. 
 
You have been asked to pay a $75 copayment for computed tomography (CT scan). This item/service falls 
within the Radiological diagnostic 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 computed tomography (CT scan) provided on May 31, 2022. 
 Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.