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

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services
provided from March 1, 2022, to March 18, 2022.
You asked the Plan to waive the copayment for the SNF services. You say that you are appealing because you
find it too much of a copayment and you feel your insurance should have covered all of it. 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 $178
copayment for per day for days 21-100 of SNF care.
You have been asked to pay a $1,958 copayment for the SNF services. The Plan has submitted documentation
to show you were in the SNF from February 15, 2022, through March 18, 2022, for a total of thirty-one (31)
days. You have been asked to pay a copayment for eleven (11) days for a total of $1,958. This item/service
falls within the days 21-100 of SNF care 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 the skilled nursing facility (SNF) services provided from March 1, 2022, to March 18, 2022.
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 enrollee will make measurable progress and 
improve functional impairments. The Plan denied your request. The Plan says the records do not show that the 
enrollee meets the criteria for an inpatient rehabilitation facility. 
 
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 enrollee is medically stable. The enrollee's therapy needs are routine. While the 
enrollee may benefit from physical and occupational therapy their needs can be provided in a lower intensity 
and alternate setting such as continuing home with services. 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the services are medically necessary. The Plan denied your request. The Plan says Medicare rules do not allow the health plan to pay for services when prisoners are in custody during their admission. Maximus overturned the Plan's denial based on medical necessity. The Plan requested reopening and stated the denial was not based on medical necessity but for the fact the enrollee was incarcerated at the time of admission. The Plan is correct in this case.
Medicare rules say that payment may not be made for services furnished without charge to individuals who have been committed under a penal statute.
The file indicates the enrollee was a prisoner when these services were requested. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a refill for an intrathecal pain pump.
You asked the Plan to pre-approve a refill for an intrathecal pain pump. You say that the requested service is a medical necessity for you. The Plan denied your request. The Plan says that the request is not medically necessary because there is no order for the requested service from your primary care physician.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules.
These services have not been denied for medical necessity but for the fact that your physician did not submit a signed refill to indicate how many units were being administered through the pump. Therefore, we decided that the Plan does not have to pre-approve a refill for an intrathecal pain pump.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories/features/power options.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no need for the power option included with the requested power wheelchair.
Our Medical director looked at the case file and the reopen request. At issue is coverage for a group 3 power wheelchair with accessories/features/power options. Our Medical Director states that the clinical documentation does not sufficiently support that you were able to safely and independently operate a power wheelchair. Medicare guidelines state that you must have the mental and physical capabilities to safely operate the power wheelchair that is provided or have a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is provided. Our physician reviewer found that your condition does not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a group 3 power wheelchair with accessories/features/power options.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0241U provided on December 7, 2022. 
 
You asked the Plan to pay for procedure code 0241U. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 0241U 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 0241U 
provided on December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0463 billed for date of service March 28, 
2022. 
 You asked the Plan to pay for procedure code G0463. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code G0463 is bundled into 
payment for code G0438. 
 
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 G0463 
is a column II code to column I code G0438. 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 G0463 billed for date of service March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 91200 provided on September 14, 2022. 
 
You asked the Plan to pay for procedure code 91200. 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. 
 
Medicare guidelines say that ICD-10-CM has a coding convention that requires the underlying condition to be 
sequenced first, followed by the manifestation. In this case, K74.00 is a manifestation code and cannot be used 
as the primary or first-listed diagnosis code on the claim. Therefore, we decided that the Plan does not have to 
pay for procedure code 91200 provided on September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on May 4,
2022.
You asked the Plan to pay for the laboratory services. You say that you disagree with the denial. The Plan
denied your request. The Plan says the claim for this molecular pathology testing did not include the required
unique identifier.
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue,
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the
coverage status is listed in the DEXTM Diagnostics Exchange.
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services
provided to the enrollee on May 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for radiology services provided to the enrollee on April 25, 2022.
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 Medicare billing criteria were not met. Maximus partially overturned the Plans denial.
The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan
provided documentation to show that per National Correct Coding Initiatives (NCCI) Procedure to Procedure
(PTP) edit exists between 77067 and 77066. Per National Correct Coding Initiatives (NCCI), the PTP edit
between these code pairs has a modifier indicator of "1" which states modifiers associated with NCCI are
allowed, however, an appropriate NCCI modifier was not billed. Per NCCI Chapter 1 - General Correct Coding
Policies, Section E - Modifiers and Modifier Indicators: The AMA "CPT Manual" and CMS define modifiers
that may be appended to HCPCS/CPT codes to provide additional information about the services rendered.
Modifiers consist of 2 alphanumeric characters. Modifiers may be appended to HCPCS/CPT codes only if the
clinical circumstances justify the use of the modifier. A modifier shall not be appended to a HCPCS/CPT code
solely to bypass an NCCI PTP edit if the clinical circumstances do not justify its use. If the Medicare program
imposes restrictions on the use of a modifier, the modifier may only be used to bypass an NCCI PTP edit if the
Medicare restrictions are fulfilled. Modifiers that may be used under appropriate clinical circumstances to
bypass an NCCI PTP edit include Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC,
LM, RI Global surgery modifiers: 24, 25, 57, 58, 78, 79 Other modifiers: 27, 59, 91, XE, XS, XP, XU.
Modifiers 76 ("Repeat Procedure or Service by Same Physician") and 77 ("Repeat Procedure by Another
Physician") are not NCCI PTP-associated modifiers. Use of either of these modifiers does not bypass an NCCI
PTP edit. Each NCCI PTP edit has an assigned modifier indicator. A modifier indicator of "0" indicates that
NCCI PTP-associated modifiers cannot be used to bypass the edit. A modifier indicator of "1" indicates that
NCCI PTP-associated modifiers may be used to bypass an edit under appropriate circumstances. A modifier
indicator of "9" indicates that the edit has been deleted, and the modifier indicator is not relevant. Per the above
Medicare guidelines, the Plan has correctly denied code 77067 for payment as the code pair has a modifier
indicator of 1, but a correct modifier was not billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, this claim was
submitted with errors due to the PTP edits for the codes billed. Medicare rules for coverage of these services
have not been met. Therefore, we decided that the Plan does not have to pay for radiology services provided to
the enrollee on April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye examination and the refraction provided on 
September 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye examination and the refraction. You say that this plan does not need a 
referral for the services. You say your facility should not be considered a specialist. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
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 
eye examination. We found no exception that would require the Plan to pay for the eye examination.  
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers the refraction when provided as part of the routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed with a routine eye 
examination. Based on this information, we decided that the Plan's rules for coverage of the refraction have not 
been met. 
 
Therefore, we decided that the Plan does not have to pay for the eye examination and the refraction provided 
on September 7, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a filling (D2392) provided on November 15, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 
 
 The plan has agreed to pay for these services at the out-of-network rate. This means that you may be asked to 
pay the difference between the out-of-network providers charges and the Plans payment. 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 more for a filling (D2392) provided on November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on August 18, 2022. 
 
You asked the Plan to pay for laboratory testing. 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 laboratory testing 
provided on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an extraction (D7210) November 3, 2022. 
 
You asked the Plan to waive the copayment for the dental services. 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. 
 
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. 
 
You have been asked to pay a $25 copayment for a dental extraction. This item/service falls within the Dental 
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 extraction (D7210) 
November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on April 28, 2022. 
 
You asked the Plan to pay for a telehealth visit. 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 telehealth visit 
provided on April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental extraction (D7210) provided on December 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a dental 
extraction (D7210) provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid exam of both ears (92591), acoustic reflex 
testing (92568), tympanometry (impedance testing) (92567), and the comprehensive hearing test (92557) 
provided on May 17, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable as they were 
rendered by an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, the Plans contract states that hearing aids/services 
must be provided and arranged through the Plans select hearing vendor. However, the services provided in this 
case were rendered by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for 
the hearing aid exam of both ears (92591), acoustic reflex testing (92568), tympanometry (impedance testing) 
(92567), and the comprehensive hearing test (92557) provided on May 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 25, 2022, 
to March 14, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 26, 2022. The NOA was not received by the Plan until April 29, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from February 25, 2022, to March 14, 2022.