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

 
We decided that the Plan does not have to pay for hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, 
bipolar arthroplasty) rendered on September 8, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 27125 is "Hemiarthroplasty, hip, partial (eg, femoral 
stem prosthesis, bipolar arthroplasty)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the procedure details cite the 
insertion of the appropriate length 10mm nail down to the distal femur. Placed the guidewires for the recon 
screws into the femoral head. Insured center position. Measured for appropriate length, predrilled, placed the 
superior and inferior recon screws. Next moved distal and using perfect circle technique, placed 2 distal 
interlocking screws. Therefore, the records do not support that CPT 27125 was rendered in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) rendered on 
September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on June 30, 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 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 information. The Plan showed that the claim shows a place of service (POS) code billed of 81, Independent Laboratory, independent of an institution or a physician's office. The difference between the collection date (June 8, 2022) and the received date (June 11, 2022) confirms that this was not taken by the laboratory directly. An independent laboratory taking a sample in its laboratory shows "81" as place of service. If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it uses the code for the inpatient (POS code 21), off campus-outpatient hospital (POS code 19), or on campus-outpatient hospital (POS code 22), respectively. The facility notified the health plan on June 7, 2022, of an unexpected medical admission for the enrollee on June 6, 2022. The enrollee remained inpatient until July 2, 2022. The specimen was collected on June 8, 2022, during that admission. Therefore, the submitted POS code was in error.
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 could not be paid as billed due to an error with the submitted POS code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on June 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
August 16, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you did not want to be 
admitted. 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 $290 
copayment per day, for days 1 to 6 and a $0 copayment for additional days of Medicare-covered inpatient 
hospitalization.  
 
 You have been asked to pay a $290 copayment for 1 day of the inpatient hospital stay. You have not been 
charged for any additional days. This item/service falls within the inpatient hospital 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 inpatient hospital stay provided on August 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for code 70450 provided on October 14, 2022.
You asked the Plan to pay for this service. 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. The Plan requested a reopen and provided additional information. The Plan noted that per the National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit rules, an edit exists for code 70496 and 70450. Code 70496 was billed on the same date of service by the same provider as code 70450. Each edit table contains edits which are pairs of code that in general should not be reported together. Each edit has a Column One and Column Two HCPCS/CPT code. If a claim reports the 2 codes of an edit pair, the Column Two code is denied, and the Column One code is eligible for payment.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, code 70450 is a Column two code and not eligible for payment as billed. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for code 70450 provided on October 14, 2022.
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 August 25, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this should be paid for. 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 August 
25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reconstructive surgery to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve reconstructive surgery. You say that this is medically necessary and should 
be covered. The Plan denied your request. The Plan says there are other providers who are in-network who the 
patient has to see first. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
reconstructive surgery to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your previous dentures are no good and 
you are unable to eat properly with them. The Plan denied your request. The Plan says your benefit for the 
requested items or services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on the date of service of October 9, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a 
complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the dental services. You say that this dental work is medically necessary. 
The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve dental 
services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on June 30, 2022, to 
December 27, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you had the same procedure 
before and the copayment was less. 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 $250 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges. The provider billed in the 
amount of $313 and the allowed amount is $109.60. The provider also billed in the amount of $295 and the 
allowed amount is $109.60. This is less than the copayment amount. There were 4 visits. 4 x $109.60 = 
$438.40. Therefore, results in the total cost sharing amount of $438.40. 
 
You have been asked to pay $109.60 copayment, which is less than for each outpatient surgery. This 
item/service falls within the outpatient surgery and other medical services provided at hospital outpatient 
facilities and ambulatory surgical centers 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 outpatient surgery on June 30, 2022, to December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown - porcelain fused to high 
noble alloys tooth #30 (D6066). 
 
You asked the Plan to pre-approve the implant supported crown tooth #30. You say that you know this is not a 
covered service per your plan. You also say you  would like this to be approved to make an exception. The Plan 
denied your request. The Plan says this service is not covered under your dental 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 an 
implant supported crown - porcelain fused to high noble alloys tooth #30 (D6066).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on March 20, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that the records attached support 
the services provided. 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 subsequent nursing 
facility care visits provided on March 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam (D0364) and endodontic therapy (D3332) 
for tooth #29. 
 
You asked the Plan to pre-approve the dental services. You say that you have a broken tooth and it is causing 
suffering and you would like the Plan to cover the dental services.The Plan denied your request. The Plan says 
the denial of authorization for these services is correct, because the cone beam and endodontic therapy are not 
covered by the Plan. 
 
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 a 
cone beam (D0364) and endodontic therapy (D3332) for tooth #29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodental scaling and root planing (D4341) provided on 
January 25, 2023. 
 
You asked the Plan to pay for periodental scaling and root planing. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
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 
periodental scaling and root planing (D4341) provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), cone 
beam computed tomography (CT) capture and interpretation (D0364), pulp vitality tests (D0460), and pulpal 
debridement (D3221) provided on February 14, 2023. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, cone beam CT capture and 
interpretation, pulp vitality tests, and pulpal debridement. You say that you made sure you went to a contracted 
orthodontist. You also say that you do not agree in how you were supposed to know the coded services were 
not covered by the Plan. The Plan denied your request. The Plan says these services are not covered 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 the 
problem focused limited oral evaluation (D0140), cone beam computed tomography (CT) capture and 
interpretation (D0364), pulp vitality tests (D0460), and pulpal debridement (D3221) provided on February 14, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and cleaning (D1110, D0120) 
provided on March 4, 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 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 periodic oral evaluation and cleaning (D1110, D0120) provided on March 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown and core buildup services (D2740, D2950) provided 
on December 13, 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 crown 
and core buildup services (D2740, D2950) provided on December 13, 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 benefit from frequent physician 
oversight for their multiple complex comorbidities. The Plan denied your request. The Plan says the services 
are not medically necessary.  
 
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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a CT scan provided on December 8, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you were in the office for 10 minutes 
for one test but was charged for two. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms 
how much you should expect to pay for each Medicare-covered diagnostic CT scan provided on the same day.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $50 
copayment for each Medicare-covered diagnostic CT scan at a freestanding provider. The Plan contract does 
not clearly say how much enrollees must pay for multiple Medicare-covered diagnostic CT scans performed on 
the same day by the same provider. This means that the Plan did not follow Medicare rules for disclosure of 
cost sharing information. Therefore, we decided that the Plan has to waive the copayment for a CT scan 
provided on December 8, 2022.  
 
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.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for an arthrocentesis provided on March 8, 2023, and 
March 22, 2023. 
 
You asked the Plan to reduce the copayment for an arthrocentesis. You say that you have never had to pay a 
$325 copayment when getting these injections at previous provider. The Plan denied your request. The Plan 
says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $50 copayment for a minor surgical and other procedures 
in an outpatient hospital. 
 
The Plan says you must pay a $325 copayment for an arthrocentesis. Based on the Plan contract, however, you 
cannot be asked to pay more than a $50 copayment for an arthrocentesis. Therefore, we decided that the Plan 
has to reduce the copayment for an arthrocentesis provided on March 8, 2023, and March 22, 2023. 
 
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.