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

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain 
(70450) provided on January 16, 2021. 
 
You asked the Plan to pay for the CT services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says an appropriate modifier was not billed with the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) 
provided on January 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
September 18, 2019, through September 30, 2019, billed with code LE1. 
 
You asked the Plan to pay for the SNF services as billed. You say that you have submitted the required 5-day 
assessment with your appeal to support the coding of this claim. The Plan denied your request. The Plan says 
there was no 5-day assessment provided so payment can only be approved at the default rate using code AAA. 
 
The Plan must follow Medicare rules. Medicare rules say that for SNF billing, the HIPPS code is calculated 
based on information from the required assessments. The first assessment is the 5-day assessment which must 
be completed within 14 days after the ARD date.  
 
In this case, although the appeal included a completed 5-day assessment, this was not completed until 
November 30, 2020, which is more than 14 days after the ARD date of September 24, 2019. Therefore, we 
decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
September 18, 2019, through September 30, 2019, billed with code LE1.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on June 
8, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not have been 
charged a $40 copayment because you did not see the doctor. The Plan denied your request. The Plan says you 
have been asked to pay the correct cost-sharing amount. 
 
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 $40 
copayment for an in-network specialist visit.  
 
You have been asked to pay a $40 copayment for a specialist office visit. The specialist office visit falls within 
the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you 
were seen in an oncology office which is considered a specialist office. 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 specialist office visit provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam provided on April 12, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the amalgam. You say that you had the advanced dental plan. The Plan denied 
your request. The Plan says the treating provider does not have a contract with the Plan as a participating 
provider and is allowed to bill the difference of the allowed amount and their billed amount to you. 
 
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 in excess of Medicare coverage, the contract says that you are 
responsible for a 20% coinsurance of the covered Plan allowance after the $100 annual deductible is met, plus 
the difference between the billed amount and allowed amount for the service being received OON. The record 
shows that the allowed amount for the amalgam ($96.80) is less than the $100 deductible, and you are 
responsible for the full allowed amount plus the difference between the billed amount and allowed amount, 
which means you are responsible for the payment in full. Therefore, we decided that the Plan does not have to 
pay for the amalgam provided on April 12, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a re-cement or re-bond of a crown (D2920) provided on June 
23, 2021. 
 
You asked the Plan to pay for a re-cement or re-bond of a crown. You say that you are requesting 
reconsideration of payment due to lack of benefit knowledge. The Plan denied your request. The Plan says re-
cement or re-bond of a crown is covered at 50% every five calendar years. 
 
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. The Plan covers a re-cement 
or re-bond of a crown once every five years.  
 
We looked at the file and Medicare rules. The records show that you received a re-cement or re-bond of a 
crown on March 17, 2021, therefore, you have exhausted your maximum benefit for this service. Based on this 
information, we decided that the Plan's rules for coverage of a re-cement or re-bond of a crown have not been 
met. Therefore, we decided that the Plan does not have to pay for a re-cement or re-bond of a crown (D2920) 
provided on June 23, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram services provided on April 19, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the records support the level of service 
provided. The Plan denied your request. The Plan says the enrollee received services during an inpatient 
hospitalization. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. The facility must furnish all necessary covered services 
to the beneficiary either directly or under arrangements made with outside providers.  
 
We looked at the file and the rules. The service at issue was provided via arrangement of the facility. Payment 
for this service would have been included under the facility claim. Payment to you for this service is the 
responsibility of the facility. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram services 
provided on April 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not show an illness that requires further hospital care, or a 
need for daily doctor visits or special nursing care. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services medically necessary, reasonable, 
and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively 
only on an inpatient basis. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the food and sales tax charges provided April 5, 
2021, to April 30, 2021. 
 
You asked the Plan to reimburse you for the food and sales tax charges. You say that you would like to be 
further reimbursed for food and sales tax. The Plan denied your request. The Plan says these services are not 
among those covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that when the Plan provides transplant services at a 
distant location, farther away than the normal community patterns of care for transplant services, they must 
provide reasonable travel and lodging. The rules also say that sales tax is not reimbursed. 
 
We looked at the file and Medicare rules. In this case, the items you are requesting reimbursement for, food 
and sales tax, are both not covered by Medicare or the Plan. Based on this information, we decided that 
Medicare rules for coverage of the food and sales tax charges have not been met. Therefore, we decided that 
the Plan does not have to reimburse you for the food and sales tax charges provided April 5, 2021, to April 30, 
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the magnetic resonance imaging (MRI) performed on 10/28/21 did not document any 
bone marrow edema. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the medical records do not show that the fracture is acute and less than six weeks old. Therefore, the 
criteria are not met. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage (I&D) of an abscess provided on 
September 20, 2019, billed with code 10061. 
 
You asked the Plan to pay for the I&D service as billed. You say that you have been attempting to get this 
claim paid in full for a long time. You have been paid and had payments reversed multiple times on different 
claims. It is felt that the documentation supports that payment should be made, and that Medicare pays for 
these services when provided by a podiatrist. The Plan denied your request. The Plan says the only code that 
cannot be paid is 10061 as this is not reported with a valid diagnosis code for podiatrist services.  
 
The Plan must follow Medicare rules. Medicare rules say that podiatrist reimbursement for treatment of 
abscesses is limited to certain diagnoses. The rules indicate that only diagnosis codes L02.611, L02.612, and 
L98.8 will be allowed for payment of code 10061. 
 
None of the claims processed by the Plan list code 10061 with a covered diagnosis for podiatry. As such, we 
find that the Medicare criteria for payment of the I&D service as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the incision and drainage (I&D) of an abscess provided on 
September 20, 2019, billed with code 10061.  
 
We note that it appears a corrected claim was submitted directly to Maximus during the review of this case. We 
cannot act on or process claim corrections. Corrected claim information may be submitted directly to the Plan 
for further review. We are only permitted to make a decision based on the claim information reviewed by the 
Plan for payment. Please submit any corrections or additional claim information directly to the Plan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a pharmacogenetic panel (81225, 81227, 81226, 81223, 
81241, 81328, 81335, 81400, 81401, 81230, 81231, 81240, 81232, 81406, 81350, 81479, 81291, 81306) 
provided on April 29, 2021. 
 
You asked the Plan to pay for a pharmacogenetic panel. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. If a laboratory assays 2 or more genes in a 
patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a 
single procedural service, so 1 code must be submitted for the panel. 
 
We find that CPT codes 81225, 81227, 81226, 81223, 81241, 81328, 81335, 81400, 81401, 81230, 81231, 
81240, 81232, 81406, 81350, 81479, 81291, and 81306 are not supported in the medical record. Specifically, 
these codes were used to report a panel, which should be billed with one code. Based on this information, we 
decided that Medicare rules for coverage of a pharmacogenetic panel have not been met. Therefore, we decided 
that the Plan does not have to pay for a pharmacogenetic panel (81225, 81227, 81226, 81223, 81241, 81328, 
81335, 81400, 81401, 81230, 81231, 81240, 81232, 81406, 81350, 81479, 81291, 81306) provided on April 29, 
2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of LTACH services from August 21, 2021, 
through present. 
 
You asked the Plan to pre-approve continuation of LTACH services. You say that LTACH services are 
medically necessary. The Plan denied your request. The Plan says continuation of LTACH services is not 
medically necessary. The enrollee can be treated at a lower level of care such as a skilled nursing facility. 
 
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 continuation of LTACH services. Our 
reviewer says that the continuation of LTACH services is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the record indicates that the enrollee was in a LTACH facility and 
continued stay denied as of August 21, 2021. The record includes daily summary notes of the enrollee's 
ongoing issues. The note from the last covered day indicates only that a trach tube for downsize was ordered. 
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, 
of the requested continued level of service. The elements of the coverage criteria are not satisfied.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of LTACH services from August 21, 2021. through present have 
not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of LTACH 
services from August 21, 2021, through present.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services you received on July 7, 
2021. 
 
You asked the Plan to waive the copayment for the urgent care services. You say that the nurse gave you an 
EKG and found nothing.  You say that the Physician's assistant checked your ears and said they looked clear.  
You stated that they told you to go to the emergency room because they didn't know what was wrong with you. 
The Plan denied your request. The Plan says you were charged this copayment 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 $50 
copayment for urgent care services.  
 
You have been asked to pay a $50 copayment for the urgent care services. This copayment applies regardless 
of your satisfaction with the services. 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 urgent care services 
you received on July 7, 2021.
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 your medical needs are being met in the current acute setting. The Plan states that LTACH would add no additional services. The Plan states with additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.
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 you appear to be worsening again and are unstable currently. You require only short-term additional acute care hospital services to stabilize you and continue weaning that can safely be administered at the current facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary as there would be insufficient clinical advantage to transferring. Transfer may be considered soon when your treatment has completed, you are more stable, and when you are appropriate for treatment 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 24, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged.  
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 February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral device to help with sleep apnea provided to the 
enrollee on June 9, 2021. 
 
You asked the Plan to pay for the oral device. You say that the services are necessary. The Plan denied your 
request. The Plan says there was no physician order to verify the billed codes. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order to support medical necessity for the supplies provided in 
this case. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the oral device to help with sleep apnea 
provided to the enrollee on June 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xenon Chloride Excimer laser treatment for the 
enrollee. 
 
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied 
your request. The Plan says the body surface area being treated is stated as 30% and 10% is appropriate. 
 
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 treatment. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found while excimer laser is a standard treatment for certain forms of psoriasis, there is no 
justification that extent of skin involved in the treatment is appropriate. 
 
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 treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Xenon Chloride Excimer laser treatment for the enrollee.