Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the $65 cost share for a panoramic x-ray (D0330) provided on
November 3, 2022.

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 applied correctly. Maximus overturned the Plans denial
for insufficient information in the case file. The Plan requested a reopen and noted that the records do not
indicate you were referred to this dental provider. The Plan states that codes D0210 and D0330 are listed in
your dental companion coverage with limitations. Code D0330 is only covered once every 12 months. The Plan
further states on November 3, 2022, you signed a financial agreement to pay for these services if they were not
covered.

The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Code D0330 is covered once every 12 months. The Plan shows this benefit not available on the date of service.
We find the $65 cost share applied to code D0330 was applied correctly. Therefore, we decided that the Plan
does not have to waive the $65 cost share for a panoramic x-ray (D0330) provided on November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on August 06, 2023. 
 
You asked the Plan to pay for ophthalmological services. You say that there is a referral for these services. 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 ophthalmological 
services provided on August 06, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the occupational therapy visits provided on 
July 12, 2023, to October 02, 2023. 
 
You asked the Plan to reduce the copayment for the occupational therapy visits. You say that you were told 
your copayment would be $5 not $30. 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 $30 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $30 copayment for the occupational therapy visits. 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. The total you owe is $360 ($30 copayment x 12 visits = $360). Therefore, we 
decided that the Plan does not have to reduce the copayment for the occupational therapy visits provided on 
July 12, 2023, to October 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for naturopathic services provided on August 21, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for naturopathic services. You say that services by a different naturopathic physician 
were covered and that you were not aware that the physician at issue was out of network. The Plan denied your 
request. The Plan says that their original decision to deny payment was correct. 
 
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 naturopathic services provided on August 21, 
2023, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) 
provided on August 11, 2023. 
 
You asked the Plan to waive the copayment for the magnetic resonance imaging (MRI). You say that you have 
low income and you cannot afford to pay the high copayment. 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 $175 
copayment for advanced radiology services. 
 
You have been asked to pay a $175 copayment for the magnetic resonance imaging (MRI). This item/service 
falls within the advanced radiology 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 the magnetic resonance imaging (MRI) provided on August 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the leuprolide acetate suspension provided 
on August 01, 2023. 
 
You asked the Plan to waive the coinsurance for the leuprolide acetate suspension. You say that the injection 
was unnecessary and you should not have to pay. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the leuprolide acetate suspension. This item/service falls 
within the Medicare Part B prescription drugs 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. The total amount you owe is $199.03 ($995.16 allowed amount x 20% = 
$199.03). Therefore, we decided that the Plan does not have to waive the coinsurance for the leuprolide acetate 
suspension provided on August 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a home visit provided on August 11, 2023. 
 
You asked the Plan to waive the copayment for a home visit. You say that you were told that you would not be 
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). Your contract with the Plan clearly says that you must pay a $15 
copayment for each Medicare-covered podiatry visit. 
 
You have been asked to pay a $15 copayment for a home visit. This item/service falls within the each 
Medicare-covered podiatry visit 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 a 
home visit provided on August 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the end-stage renal disease related services provided on July 
31, 2023. 
 
You asked the Plan to pay for the end-stage renal disease related services. You say that you are requesting 
reconsideration of the denied claim. 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 the end-stage renal 
disease related services provided on July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by codes 
99223 billed on August 31, 2023, and 99233 billed on September 1, 2023. 
 
You asked the Plan to pay for 99223 and 99233. You say that 99223 and 99233 should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says 99223 and 
99233 are denied because they are not supported in the documentation. 
 
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 99223 is initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
The CPT Code Manual definition of code 99233 is subsequent hospital inpatient or observation care, per day, 
for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 50 minutes must be met or exceeded. 
 
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 99223 and 99233. Our reviewer says that 
99223 and 99233 are not supported in the documentation. Our reviewer found the enrollee is a 73-year-old who 
was treated in the hospital on August 31, 2023, and September 1, 2023. The documentation from these dates 
describes the enrollee as being seen post cervical fusion surgery without distress or report of complication. The 
enrollee was treated with antibiotics, simple wound care, and home medications with supportive care only. The 
documentation for August 31, 2023, did not support a high level of medical decision making and did not detail 
the duration of time spent on the encounter, therefore the billing of 99223 for this date of service is not 
supported. The documentation for September 1, 2023, also did not support a high level of medical decision 
making and did not detail the duration of time spent on the encounter, therefore the billing of 99233 for this 
date of service is not supported. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99223 and 99233 have not been met. Therefore, we decided that the Plan does 
not have to pay for the evaluation and management services described by codes 99223 billed on August 31, 
2023, and 99233 billed on September 1, 2023.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehabilitation level of
care. The Plan denied your request. The Plan says that the records received does not indicate the enrollee needs
an intensive therapy program with multiple visits from a rehabilitation physician per week. Maximus
overturned the Plan's denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria.

The Plan is correct in this case. 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. The
rules are clear that you must meet specific criteria prior to admission for IRF care to be covered. The records
clearly show that at the time of the appeal prior to admission the enrollee did not meet all the criteria required
by Medicare for coverage. Therefore, we decided that the Plan does not have to pre-approve acute inpatient
rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for upgraded electronics for a power wheelchair
(E2313 and E2377).

You asked the Plan to provide coverage for these accessories. You say that at the time of the appeal, these
accessories were medically necessary. The Plan denied your request. The Plan says the required coverage
criteria for upgraded electronics were not met. The Plan noted that because you are dual eligible you should
contact Medicaid for possible coverage for these accessories. Maximus overturned the Plans denial
administratively for no medical records. The Plan requested a reopen and provided the required medical
records.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. The available clinical documentation does not
support that the requested upgraded electronics were medically reasonable and necessary in this case. The
medical records do not show you are unable to operate the power wheelchair with the standard approved
switches included in the power wheelchair base. Medicare rules for coverage of these accessories have not been
met. Therefore, we decided that the Plan does not have to provide coverage for upgraded electronics for use
with a power wheelchair (E2313 and E2377).
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the enrollee meets criteria for admission. The Plan
denied your request. The Plan says that based on the available information, admission to IRF is not reasonable
and necessary, as the enrollee's condition does not meet the Medicare criteria. Maximus overturned the Plan's
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. 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. The
rules are clear that you must meet specific criteria prior to admission for IRF care to be covered. The records
clearly show that at the time of the appeal prior to admission the enrollee did not meet all the criteria required
by Medicare for coverage. Therefore, we decided that the Plan does not have to pre-approve acute inpatient
rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for code 88374 billed for date of service January 6, 2023.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and provided additional clarification. The
Plan noted that the provider submitted two claims for the same date of service for code 88374. One claim was
submitted for 1 unit and the other for 8 units. As the provider billed 88374 in excess of what is allowed by
Medicare, this claim could not be paid as billed.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Medicare rules. Medicare rules say that submitted claims in which the unit of service
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess
units. The claim does not contain evidence that the excess units were provided, were correctly coded, and were
medically necessary. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have
to pay for code 88374 billed for date of service January 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87481, 87640, 87653, and 87798) provided 
on August 22, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87640, 87653, and 87798. 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 for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the panel testing (87481, 87640, 87653, and 87798) provided on August 22, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 23 fractions of image-guided, intensity-modulated 
radiation therapy (IG-IMRT) (77014, 77385). 
 
You asked the Plan to pre-approve IG-IMRT. You say that the treatment is medically necessary for the 
enrollee. The Plan denied your request. The Plan says Medicare covers tests and treatments which meet but do 
not exceed the enrollee's medical need. Prostate radiation is not considered necessary for the enrollee's stage of 
cancer past 20 treatments. 
 
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 IG-IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is being offered 43 fractions of intensity-modulated radiation therapy (IMRT) in 
the setting of a single bone and nodal metastasis. The delivery of greater than 43 fractions of radiation in the 
metastatic setting seems outside of the standard of care based on National Comprehensive Cancer Network 
(NCCN) guidelines. The case file does not adequately document the need for going outside of the standard of 
care. The letter of appeal argues that the proximity of the bone lesion to the prostate necessitates more 
fractions. It is unclear why this would be the case. The bone lesion and prostate can be encompassed in 1 field, 
and the dose can be painted as appropriate. But there is no evidence-based (or plausible) rationale for doing this 
in greater than 20 fractions. IMRT is appropriate for this enrollee though there is no plausible justification for 
more than 20 fractions. The decision is unfavorable for the additional fractions of IMRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IG-IMRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 23 fractions of image-guided, intensity-modulated radiation therapy (IG-IMRT) (77014, 77385).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87640, 87651, 87653, 87798) provided 
on August 17, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (87481, 87640, 87651, 87653, 87798) provided on August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99000 billed for date of service June 16, 
2023. 
 
You asked the Plan to pay for procedure code 99000. You say that the claim was denied incorrectly. The Plan 
denied your request. The Plan says procedure code 99000 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 99000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99000 billed for date of service June 16, 2023.