Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from July 8, 2020,
to July 14, 2020, at the Diagnosis Related Group (DRG) originally billed.

You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these
services were medically necessary and were reported appropriately. The Plan denied your request. The Plan
says that that these services are not supported as billed. Maximus overturned the Plan's denial because of a lack
of information. The Plan requested a reopening and provided records for review.

Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital
services at the DRG originally billed. Our Medical Director states that the enrollee has a diagnosis of metastatic
cancer, who was admitted to the hospital for repair of a pathological left radius fracture. On July 10, 2020, the
enrollee underwent open biopsy of a left radius bone lesion, removal of malignant tumor, and open
reduction/internal fixation of the left radius. On July 12, 2020, the enrollee was confused, febrile, and
tachycardic, and had an elevated white blood cell count. The available clinical documentation is insufficient to
support a DRG downgrade from 477 to 478. Our physician reviewer found that the enrollee's condition meets

criteria for payment of the inpatient hospital services at the DRG originally billed.
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 inpatient
hospital services provided to the enrollee from July 8, 2020, to July 14, 2020, at the Diagnosis Related Group
(DRG) originally billed.

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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99285) provided on July 20, 
2023. 
 
You asked the Plan to pay for an emergency department visit (99285). You say that procedure code 99285 is 
appropriate based on the services performed. The Plan denied your request. The Plan says the records do not 
support the services at issue 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 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 a medically appropriate history and/or examination and high level 
of medical decision making. 
 
 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 an emergency department visit (99285). Our reviewer says 
that the service at issue in this case is not supported by the medical records. Our reviewer found the enrollee 
was evaluated in the emergency department (ED) for post-operative, right leg, pain and swelling. The 
documentation supports that an appropriate history and physical were provided; However, the medical decision 
making was not of high complexity. As such, the billing of CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (99285) have not been met. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit (99285) provided on July 20, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for medical and surgical supplies provided on 
September 27, 2023. 
 
You asked the Plan to waive the coinsurance for medical and surgical supplies. You say that you should not 
have to pay for these items. 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 each Medicare-covered medical supply. 
 
You have been asked to pay 20% coinsurance for medical and surgical supplies. This item/service falls within 
the each Medicare-covered medical supply 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 $334.88 ($1,674.43 allowed amount x 20% = 
$334.88). Therefore, we decided that the Plan does not have to waive the coinsurance for medical and surgical 
supplies provided on September 27, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99285) provided on July 13, 
2023. 
 
You asked the Plan to pay for an emergency department visit (99285). You say that procedure code 99285 is 
appropriate based on the services performed. The Plan denied your request. The Plan says the records do not 
support the services at issue 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 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 a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (99285). Our reviewer says 
that the service at issue in this case is not supported by the medical records. Our reviewer found the enrollee 
was evaluated in the emergency department (ED) for abdominal pain. The documentation supports that an 
appropriate history and physical were provided; However, the medical decision making was not of high 
complexity. As such, the billing of CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (99285) have not been met. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit (99285) provided on July 13, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on September 07, 
2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that you are supposed to have a zero 
dollar copayment and the charges should be corrected. 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 $25 
copayment for physician/practitioner services. 
 
You have been asked to pay a $25 copayment for the office visit. This item/service falls within the 
physician/practitioner 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 records show this office visit was provided by a specialist. Therefore, we 
decided that the Plan does not have to waive the copayment for the office visit provided on September 07, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone graft replacement (D7953) and bone graft for repair of 
peri-implant defect (D6103) provided on June 27, 2023. 
 
You asked the Plan to pay for these dental services. 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 bone graft 
replacement (D7953) and bone graft for repair of peri-implant defect (D6103) provided on June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS3D test provided on November 29, 2022. 
 You asked the Plan to pay for the WATS3D test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says screening for Barrett's esophagus is not a covered screening service. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the WATS3D test, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the WATS3D test provided on November 29, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99285) provided on July 22, 
2023. 
 
You asked the Plan to pay for an emergency department visit (99285). You say that procedure code 99285 is 
appropriate based on the services performed. The Plan denied your request. The Plan says the records do not 
support the services at issue 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 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 a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (99285). Our reviewer says 
that the service at issue in this case is not supported by the medical records. Our reviewer found the enrollee 
was evaluated in the emergency department (ED) for a headache and neck pain. The documentation supports 
that an appropriate history and physical were provided; However, the medical decision making was not of high 
complexity. As such, the billing of CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (99285) have not been met. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit (99285) provided on July 22, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) and intraoral - periapical 
first radiographic x-ray (D0220) provided on October 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that this visit was a follow up visit to the tooth 
extraction on July 3, 2023, therefore this should be covered by your Plan. The Plan denied your request. The 
Plan says your benefit for the requested item or service 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 item or service was exhausted on date of service July 3, 2023. Therefore, 
we decided that the Plan does not have to pay for limited oral evaluation (D0140) and intraoral - periapical first 
radiographic x-ray (D0220) provided on October 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on October 9, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 
the physician services provided on October 9, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on July 24, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted the medical 
documentation to support the medical necessity and that the claim be reprocessed and paid. The Plan denied 
your request. The Plan says the provider is not a plan contract provider and is not enrolled in Medicare as a 
durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on July 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on July 23, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted the medical 
documentation to support the medical necessity and that the claim be reprocessed and paid. The Plan denied 
your request. The Plan says the provider is not a plan contract provider and is not enrolled in Medicare as a 
durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on July 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care from June 2, 2022, to June 25,
2022, as originally billed.

You asked the Plan to pay for this claim as originally billed. You say that this claim should be paid as billed.
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 noted that initially this claim was denied on November 30, 2022, due to the
facility not providing a detailed line by line itemized bill for review. Without the itemized bill we were unable
to validate any of the charges billed by the provider. Total claim charges were $208,710.44. Once the itemized
bill was received on May 31, 2023, the Plan completed their review. Several items and services initially denied
due to not having an itemized bill have now been identified as routine items and services. The Plan continues to
uphold the denial of the routine items and services billed with denial code "G", and the total amount denied
was $19,513.83. These items and services were determined to be inclusive to either room and board or the
procedure charge and are not separately reimbursed. Additionally, after review of both the itemized bill and the
medical records received, the remaining denied charges totaling $189,196.61 initially denied for a missing
itemized bill and/or missing medical records are now approved. The facility has recently provided the itemized
bill allowing the Plan to identify and validate the charges utilizing both the itemized bill and medical records
provided.

In summary, the Plan upheld the denied charges in the amount of $19,513.83. The Plan approved charges in the
amount of $189,196.61. The review finding resulted in a revised total reimbursement amount of $ 13,571.92.
The Plan included the itemized Bill Summary of approved and denied charges for review.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The
Plan has demonstrated what codes were denied and why. Based on this information, we decided that Medicare
rules for coverage of this claim as originally billed have not been met. Therefore, we decided that the Plan does
not have to pay for You asked the Plan to pay for the inpatient hospital care billed for dates of service June 2,
2022, to June 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service August 24, 2023, billed with code 99153.  

You asked the Plan to pay for procedure code 99153. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says code 99153 is not payable in the facility 
setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service August 24, 2023, billed 
with code 99153.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 70498, 70496, and 71045 billed for April 18, 2023.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 70498, 70496, and 71045 are not supported.

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 70498 is computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing. The definition of code 70496 is computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing. The definition of code 71045 is radiologic examination, chest; single view. 

We find that CPT codes 70498, 70496, and 71045 are not supported in the medical record. Specifically, there are no submitted reports and interpretations for the billed codes. 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 pay for procedure codes 70498, 70496, and 71045 billed for April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service billed with codes 87640, 87511, 
87500, 87481, 87653, 87798 and 87801, provided on July 10, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you provided services in good faith that you 
would be reimbursed. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
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 laboratory service billed with codes 87640, 87511, 87500, 87481, 87653, 
87798 and 87801, provided on July 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 18, 2023, billed 
with codes 81432 and 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 18, 2023, billed with codes 81432 and 81433.