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

We decided that the Plan does not have to pay for procedure code J3490 billed to the enrollee for date of service November 28, 2022.
You asked the Plan to pay for code J3490. You say that the drug was a medically necessary part of the enrollee's treatment. The Plan denied your request. The Plan says that the code is included in the global surgery period for code 27096. The Plan requested a reopen and demonstrated that the unlisted code J3490 for NDC 00409115902 was properly denied, because Bupivacaine is a local anesthetic agent that cannot be separately reimbursed from the injection procedure 27096 that was billed on the same claim. Per Medicare Claims Processing Manual Chapter 12, Section 30.5.C - Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy): A therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration, is for the administration of substances/drugs.
The fluid used to administer the drug (s) is incidental hydration and is not separately payable. If performed to facilitate the infusion or injection or hydration, the following services and items are included and are not separately billable: 1. Use of local anesthesia; 2. IV start; 3. Access to indwelling IV, subcutaneous catheter or port; 4. Flush at conclusion of infusion; and 5. Standard tubing, syringes and supplies.
Payment for the above is included in the payment for the chemotherapy administration or non-chemotherapy injection and infusion service. Per the above Medicare guidelines, the Plan has correctly denied J3490 for payment as payment for the local anesthetic is included in the payment for the chemotherapy administration or non-chemotherapy injection and infusion service
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, payment for code J3490 in this case was included in the payment for the administration and infusion services. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 billed to the enrollee for date of service November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of residual tooth roots (cutting procedure) (D7250) 
x8 and alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310) 
x2 provided on January 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you say that you cannot afford to pay anymore 
for the services you received.  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. This benefit includes the 
requested removal of residual tooth roots (cutting procedure) (D7250) and alveoloplasty in conjunction with 
extractions - four or more teeth or tooth spaces, per quadrant (D7310) but is limited to two procedure codes per 
calendar year  oral surgery. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, 
per quadrant (D7310) x2 on January 31, 2023. Therefore, this benefit has been exhausted. Although D7250 and 
D7310 are two different services, they fall within the same category in your Evidence of Coverage and are 
subject to the same frequency limitations. Therefore, we decided that the Plan does not have to pay for removal 
of residual tooth roots (cutting procedure) (D7250) x8 and alveoloplasty in conjunction with extractions - four 
or more teeth or tooth spaces, per quadrant (D7310) x2 provided on January 31, 2023.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for (Claim A).
You asked the Plan to pay for Claim A. You say that this claim should be paid. The Plan denied your request. The Plan says these services were paid on Claim B. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan noted this claim denied due to previous payment for the same date of service from the same provider. The Plan showed documentation that Claim B for the same service and billed by the same provider was paid by the Plan in the amount of $181.83 on October 2, 2023.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems.
Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for code 99285 provided to the enrollee on September 9, 2022, and billed under Claim A.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve side guards and bolt-on push handles (K0108x2). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee is unable to walk and 
needs this equipment. You are requesting reconsideration. The Plan denied your request. The Plan says the side 
guards and push handles do not meet the Medicare criteria for durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve side guards and bolt-on push handles (K0108x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care and intensive care unit services provided by to the enrollee from October 23, 2022, to November 8, 2022, under claim.
You asked the Plan to pay for inpatient hospital care and intensive care unit services. You say that you are requesting a reimbursement of the full amount.
The Plan denied your request. The Plan says those services coded correctly were paid at the Medicare allowable rate that would be covered by Original Medicare. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided the claim and the Explanation of Benefits explaining how the services were paid. The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The enrollee's contract with the Plan clearly says the Plan will only pay for services provided out of the country at the Original Medicare rate. Review of the Explanation of Benefits shows the Plan paid those codes that were allowed by Medicare at the Medicare allowable rate, as they would have if the provider had been in the United States. As Medicare does not cover services provided out of the country, this payment by the Plan is a supplemental benefit and subject to the Plan's rules for claim submission. It should also be noted the Plan is unable to compel providers to submit the Medicare standard codes that would be expected from providers in the United States. Therefore, we decided that the Plan does not have to pay for inpatient hospital care and intensive care unit services provided to the enrollee from October 23, 2022, to November 8, 2022, under claim.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown for tooth #22 (D6752). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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. Therefore, we decided that the Plan does 
not have to pre-approve retainer crown for tooth #22 (D6752).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the physician charges for an office visit 
provided on December 14, 2022. 
 
You asked the Plan to waive the cost share for an office visit. You say that this should be covered at 100%. 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. Your 
contract with the Plan says that there is a $800 deductible which applies to an office visit. The Plan contract 
also says that the enrollee must pay 10% coinsurance of the approved amount for an office visit. 
 
According to the EOC, may also be charged a cost share amount if a service performed is outside of the scope 
of the annual wellness visit. The office visit you asked the Plan to waive the cost share for falls within the 
doctor and other health care provider services benefit category. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $800 deductible which applies to an office visit. This cost 
sharing is a contractual obligation that had not been met at the time an office visit was received on December 
14, 2022.  
 
You have also been asked to pay up to 10% coinsurance for the office visit. You have been asked to pay a total 
of $96.36 ($86.72 deductible + $9.64 coinsurance = $96.36). 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 cost share 
for the physician charges for an office visit provided on December 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on April 26, 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 Medicare coverage criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file regarding the ordering provider. The Plan requested a reopen and confirmed the ordering provider was also not in network and no prior authorization was requested.
The Plan is correct in this case. Medicare rules say that plans can require enrollees' prior authorization. The contract with the Plan says that this type of service may require prior authorization. There is no indication prior authorization was requested. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax provided on December 16, 2022. 
 
You asked the Plan to pay for the sales tax. You say that you have a $200 eyewear allowance and should be 
reimbursed for the full amount of the claim. The Plan denied your request. The Plan says the claim has been 
reprocessed because the provider is in-network. However, the sales tax is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover sales tax. 
 
We looked at the file and the Plan's rules. Specifically, the sales tax is not a covered benefit. The record shows 
you paid a total of $197.64 for the vision items. The Plan will cover the $183 for the lenses and frames. This 
means you are responsible for $14.64 sales tax. Based on this information, we decided that the Plan's rules for 
coverage of the sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the 
sales tax provided on December 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the semi-precision attachment abutment (D6052). 
 
You asked the Plan to pre-approve the complete denture - maxillary, mandibular partial denture, and semi-
precision attachment abutment. The Plan denied your request. The Plan says these services are not covered 
under the benefit package.  
 
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 semi-precision attachment 
abutment are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve the semi-precision attachment abutment (D6052).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have pay additional reimbursement for services provided to the enrollee from October 23, 2022, to November 27, 2022.
You asked the Plan pay additional reimbursement for services provided to the enrollee. You stated the Plan has not paid enough for the services rendered.
The Plan denied your request. The Plan says those services coded correctly were paid at the Medicare allowable rate that would be covered by Original Medicare. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided the claim and the Explanation of Benefits explaining how the services were paid.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The enrollee's contract with the Plan clearly says the Plan will only pay for services provided out of the country at the Original Medicare rate. Review of the Explanation of Benefits shows the Plan paid those codes that were allowed by Medicare at the Medicare allowable rate, as they would have if the provider had been in the United States. As Medicare does not cover services provided out of the country, this payment by the Plan is a supplemental benefit and subject to the Plan's rules for claim submission. It should also be noted the Plan is unable to compel providers to submit the Medicare standard codes that would be expected from providers in the United States. Therefore, we decided that the Plan does not have pay additional reimbursement for services provided to the enrollee October 23, 2022, to November 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG); recording in coma or sleep 
only (95822-26-XU) provided on February 15, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says 95822-26-XU is not supported by the medical records submitted. The Plan states the submitted 
medical records do not indicate that electroencephalogram (EEG); recording in coma or sleep only was 
performed. The Plan states there is a more appropriate Current Procedural Terminology (CPT) code (95955) 
that should be used to bill for the service provided.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The procedure report describes neuromonitoring services provided for 
Posterior Fusion procedures. In this case, there is a more appropriate code to report for service provided, as 
well as, CPT 95822 is not supported in the procedure report, and therefore, cannot be verified. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the electroencephalogram (EEG); recording in coma or sleep only (95822-26-XU) provided on 
February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical collar (L0180) provided to the enrollee on November 9, 2022.
You asked the Plan to pay for the cervical collar. You say that the requested item is medically necessary for the enrollee. The Plan denied your request.
The Plan says that the provided documentation did not sufficiently support the billed supply code. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid physician order, proof of delivery and relevant medical records which support medical necessity. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The medical records submitted do not discuss the need for a cervical collar. 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 cervical collar (L0180) provided to the enrollee on November 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services D6010 (x4), D7210 (x10), D6191 (x1), 
D6104 (x1), D6192, D6920 and D0367. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the criteria for approval have not been 
met. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 49020-XS-78-82 rendered on February 14, 2023.

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 documents received do not support that the procedure or service was distinct from other services performed.

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 49020 is "Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open."

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 although the operative report includes documentation to support CPT 49020, the documentation does not support a separate structure - a service that is distinct because it was performed on a separate organ/structure.  A more comprehensive procedure was performed, which in this case is a gastrectomy. The reported modifier XS cannot be verified.

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 procedure code 49020-XS-78-82 rendered on February 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
April 11, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you did not ask to be 
taken to the emergency room. 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 $90 
copayment for emergency care.  
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
emergency 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.[Additional text, if present.]Therefore, we decided that the Plan does not have to waive the copayment for 
the emergency room visit provided on April 11, 2023.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on April 11, 2023.

You asked the Plan to waive the copayment for the emergency room visit. You say that you did not ask to be taken to the emergency room. 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 $90 copayment for emergency care.

You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the emergency 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 emergency room visit provided on April 11, 2023.