Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4930 billed for date of service May 12, 
2022. 
 
You asked the Plan to pay for procedure code A4930. You say that this service is medically necessary. The 
Plan denied your request. The Plan says procedure code A4930 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code A4930 has a status indicator of N on the Physician Fee Schedule. This means that 
procedure code A4930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4930 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4930 billed for date of service May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of lateral exostosis (D7471). 
 
You asked the Plan to pre-approve removal of lateral exostosis. You say that the service is necessary. The Plan 
denied your request. The Plan says the requested 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 pre-approve 
removal of lateral exostosis (D7471).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Spinergy wheelset for a wheelchair. 
 
You asked the Plan to pre-approve these services. You say that the Spinergy wheels are lightweight with 
increased strength. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have an ultralight wheelchair. The requested Spinergy wheels serve the same purpose 
as the wheels included in the approved ultralight wheelchair. Therefore, we decided that the Plan does not have 
to pre-approve a Spinergy wheelset for a wheelchair.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the $120 copayment charged for emergency room services and 20% coinsurance for Medicare Part B drugs.

You asked the Plan to waive this cost share. You say that you do not believe this cost share is 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 insufficient information in the case file. The Plan requested a reopen and provided the required information.

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 you must pay a cost share for emergency room services and Medicare Part B drugs. The claim information and the records from the Plan clearly show these services were all billed as outpatient services. 

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 $120 copayment charged for emergency room services and 20% coinsurance for Medicare Part B drugs.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatric partial hospitalization. 
 
You asked the Plan to pre-approve psychiatric partial hospitalization. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that partial hospitalization services are only covered for 
certain indications. 
 
Review of the file shows that the Plan uses Local Coverage Determination (LCD) L34196 to support their 
denial. However, LCD L34196 is not valid for your home territory of Puerto Rico. Therefore, we cannot use 
LCD L34196 to substantiate our decision. 
 
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 psychiatric partial hospitalization. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary.  Our physician reviewer found the documentation shows that you were not showing any dangerousness to self 
or others and are not exhibiting severe psychological or psychiatric impairment requiring the requested level of 
care. You are tolerating medication and not showing any perceptual disturbance, psychosis or aggressive 
behaviors. The documentation shows that your symptomatology could be treated at a lower level of care. Based 
upon review the records provided, you do not meet the criteria for treatment at a partial hospitalization level of 
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 psychiatric partial hospitalization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve psychiatric partial hospitalization.
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 would benefit from the services that 
would be provided in an IRF. The Plan denied your request. The Plan says rules for IRF care have not been 
met. 
 
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 that the enrollees nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In this case, the 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement. However, the documentation does not support that they 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the 
member would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status. The 
enrollee can receive further services at a lower level of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second facet joint injection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a second facet injection is covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has lumbar facet 
arthopathy. An initial diagnostic facet joint procedure on June 8, 2022 resulted in a 70 percent reduction in 
pain. The criteria for coverage of a second facet injection requires at least 80 percent relief of primary pain. 
Given that the criteria are not met, the repeat injection is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a second facet joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular stimulator. 
 
You asked the Plan to pre-approve an auricular stimulator. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulation will be 
denied as non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an auricular stimulator have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an auricular stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the $75 copayment charged for diagnostic services provided on January 21, 2022.
You asked the Plan to waive this copayment. You say that you do not believe this cost share is 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 partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language. The Plan says that you received diagnostic testing while at the specialist visit. The Plan contract states an enrollee may pay $30 for a specialist visit and $75 for diagnostic testing. This claim was processed to charge the $75 copayment for the diagnostic test since technically you would have been responsible for the single highest copay for services received. Therefore, instead of paying $105 dollars, you were only charged $75.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that you must pay $0 to $75 copayment for diagnostic services and tests. Based on the records provided, 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 reduce the $75 copayment charged for diagnostic services provided on January 21, 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 your nursing medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical and rehabilitation needs do not require the intensive interdisciplinary approach provided on acute inpatient 
rehabilitation. Therefore, the acute inpatient rehabilitation admission is not medically 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on January 6, 2022.
You asked the Plan for to pay for these services. You say that you do not believe this bill is correct. The Plan denied your request. The Plan says these services must be addressed under your Medicaid benefit. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services). These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to pay for these services under the Medicare benefit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services coded 76700-59 provided on July 31, 
2021. 
 
You asked the Plan to pay for the ultrasound services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the documentation does 
not support payment for the services as billed.  
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 the ultrasound services coded 76700-
59 provided on July 31, 2021, have been met. Specifically, no medical records were provided that document 
the services that were performed. Therefore, we decided that the Plan does not have to pay for the ultrasound 
services coded 76700-59 provided on July 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this laboratory does not have 
a contract with the dialysis facility regarding payment. The Plan denied your request. The Plan says Medicare 
does not separately pay for ESRD-related laboratory testing. 
 
 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided on January 11, 
2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the records do not support the code 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 code 99285 is Emergency Department visit for the evaluation 
and management of a patient, which requires 3 key components within the constraints imposed by the urgency 
of the patient's clinical condition and/or mental status: a comprehensive history, a comprehensive examination, 
and medical decision making of high complexity.  
 
We find that CPT code 99285 is not supported in the medical record. Specifically, the records do not reflect 
that the service included medical decision making of high complexity. Based on this information, we decided 
that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided 
that the Plan does not have to pay for emergency room services (99285) provided on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fixed partial denture sectioning (D9120), bone replacement 
grafts (D7953), and guided tissue regeneration (D4266) provided on March 17, 2022. 
 
You asked the Plan to pay for denture sectioning, grafts, and tissue regeneration. You say that you were told 
the provider was in-network. The Plan denied your request. The Plan says fixed partial denture sectioning 
(D9120), bone replacement grafts (D7953), and guided tissue regeneration (D4266) are not covered by 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 fixed 
partial denture sectioning (D9120), bone replacement grafts (D7953), and guided tissue regeneration (D4266) 
provided on March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periapical x-ray (D0220), crowns on tooth #14 and 15 
(D2740), and core build up on tooth #14 and 15 (D2950) provided on May 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed these services. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periapical x-ray (D0220), crowns on tooth #14 and 15 (D2740), and core build up on tooth #14 and 
15 (D2950) provided on May 3, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient services provided from November 21, 2021, to November 
23, 2021. 
 
You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says that the billed 
DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code J96.01. 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 the inpatient services. Our reviewer says that the use of diagnosis code 
J96.01 is supported by the records provided in this case. Our physician reviewer found that the pulmonologist 
documents a diagnosis of acute hypoxic failure on November 22, 2021, likely the result of chronic aspiration. 
On November 23, 2021, the enrollee was lethargic with progressive generalized weakness. The respiratory 
examination was notable for decreased breath sounds and bilateral coarse breath sounds. The use of diagnosis 
code J96.01 is supported in the medical records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the 
inpatient services provided from November 21, 2021, to November 23, 2021.  
 
 
 
 
 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.