Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on June 05, 2023, to 
June 14, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $395 copayment per admission for each medically necessary inpatient stay. Includes inpatient acute, 
inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient 
hospital care starts the day you are formally admitted to the hospital with a doctors order. The day before you 
are discharged is your last inpatient day. There were two service dates. 2 x $395 = $790. Therefore, results in 
the total cost sharing amount of $790. The enrollee has been asked to pay a $395 copayment per admission for inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for inpatient hospital stay on June 05, 2023, to June 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93306 and 99199 billed for date of service 
April 11, 2023. 
 
You asked the Plan to pay for the services. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says these codes are not supported in the records 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 93306: 
 
Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography 
 
CPT 99199: 
 
Unlisted special service, procedure or report 
 
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 provided records do not 
clearly specify that spectral Doppler and color flow Doppler were performed in this case as is required for CPT 
93306. The provided records do clarify the unlisted special service, procedure or report to support CPT 99199. 
 
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 codes 93306 and 99199 billed for date of service April 11, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 05, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were very weak and did 
not think you would make it to the car. 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 $250 
copayment for each Medicare-covered one-way ambulance trip. 
 
You have been asked to pay a $250 copayment for ambulance services. This item/service falls within the each 
Medicare-covered one-way ambulance trip 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 ambulance services provided on May 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97110 and 97012 provided on November 
21, 2022.  
 
You asked the Plan to pay for procedure codes 97110 and 97012. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the records do not support the 
services as billed. 
 
The Plan must follow Medicare rules. The rules say that the contents of the Plan of Care for Outpatient 
Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services shall contain, at minimum: 
Diagnoses; Long term treatment goals; and Type, amount, duration, and frequency of therapy services. 
 
We looked at the file and Medicare rules. The medical records provided did not include long term treatment 
goals. Therefore, we decided that the Plan does not have to pay for procedure codes 97110 and 97012 provided 
on November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an outpatient hospital service, chemotherapy drugs 
and the associated drug administration provided on May 24, 2022. 
 
You asked the Plan to waive the cost for an outpatient hospital service, chemotherapy drugs and the associated 
drug administration. You say that you disagree with the cost share applied. 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 $750 deductible which applies to outpatient hospital services, 
including an injection of an additional new drug, and 10% coinsurance for each Medicare-covered 
chemotherapy drug and the administration of that drug.  You have been asked to pay a total cost of $697.61 for an outpatient hospital service, chemotherapy drugs, and 
the associated drug administration. This total includes a $98.54 deductible for the outpatient hospital services 
and $599.07 coinsurance, which is 10% of the allowed amount for the chemotherapy drugs and the associated 
drug administration ($5990.72 allowed x 10% = $599.07). The injection of an additional new drug falls within 
the outpatient hospital services benefit category. The chemotherapy drugs and drug administration fall within 
the Medicare Part B prescription drugs benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to outpatient hospital services, including 
an injection of an additional new drug. This cost sharing is a contractual obligation that had not been met at the 
time outpatient hospital services, chemotherapy drugs and the associated administration was received on May 
24, 2022. Therefore, we decided that the Plan does not have to waive the cost for an outpatient hospital service, 
chemotherapy drugs and the associated drug administration provided on May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 TissueNext testing (81479) provided to the enrollee on September 30, 2021.
You asked the Plan to pay for the testing. You say that this testing was necessary and was reported correctly. The Plan denied your request. The Plan says that the claim was not billed with the appropriate DEX Z-code. Maximus overturned the Plans denial. The Plan noted that per the DEX Diagnostic Exchange Registry, the DEX Z-Code Z00D0 coverage status shows as "Not Covered" for Medicare billing. The Plan included the registry page that confirms this.
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 code. In this case the reported DEX-Z code is not covered for Medicare claims. Therefore, we decided that the Plan does not have to pay for the Guardant360 TissueNext testing (81479) provided to the enrollee on September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 10, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the genetic testing. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 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 contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 the genetic testing provided on May 10, 2023, by 
an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on October 6, 2022, billed with codes 81162, 81201, 81209, 81218, 81272, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81314, 81334, and 81345.
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. Maximus partially overturned the Plan's denial because there was no argument for some of the requested codes. The Plan requested a reopening and confirmed these services were not covered.
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 October 6, 2022, billed with codes 81162, 81201, 81209, 81218, 81272, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81314, 81334, and 81345.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided on January 16, 2023.
You asked the Plan to pay for the dental services. You say that you were assured you had good dental coverage and all services would be covered. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plan's denial. The Plan requested a reopening and submitted the Medicare quick reference guide for review.
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, certain limitations apply. The record shows your benefit for the requested item or service was exhausted on date of service November 16, 2022.
Therefore, we decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided on January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 8, 2022, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory services. You say that it is impossible to receive prior 
authorization in this situation. The Plan denied your request. The Plan says the services were not 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 contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 the laboratory services provided on December 8, 
2022, by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the injection, x-ray, elbow orthosis, and occupational therapy (OT) services provided from October 19, 2022, to December 6, 2022.
You asked the Plan to waive the cost-sharing for the injection, x-ray, elbow orthosis, and OT services. You say that you would like the cost share reconsidered. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the Plan's denial. The Plan requested a reopening and stated that they misquoted the cost-sharing amount in the original request. The Plan is correct in this case. They have provided your Explanation of Benefits showing the cost-share amount that was assessed was for a total of $177.49.
Date of Service
Service Rendered
Amount Allowed
Amount per Contract
Cost Share
October 19, 2022
OT Evaluation (97166)
$98.67
$25 copayment
$25
October 28, 2022
Elbow Orthosis (L3762)
$55
20% coinsurance
$11
October 28, 2022
OT services (97535)
$32.08
$25 copayment
$25
November 04, 2022
OT services (97110)
$28.82
$25 copayment
$25
November 10, 2022
OT services (97110)
$28.82
$25 copayment
$25
November 17, 2022
OT services (97140)
$26.50
$25 copayment
$25
December 6, 2022
Radex Elbow Complete x-ray (73080)
$31.52
$15 copayment
$15
December 6, 2022
OT services (99213)
$74.03
$25 copayment
$25
December 6, 2022
Injection (J1030)
$7.45
20% coinsurance
$1.49
Total
$177.49
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 has correctly charged the cost-sharing for the injection, x-ray, elbow orthosis, and occupational therapy (OT) services provided from October 19, 2022, to December 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network specialists office visit 
provided on May 08, 2023. 
 
You asked the Plan to waive the copayment for an in-network specialists office visit. You say that you were not 
seen this day. 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 $45 
copayment for Physician/Practitioner services, includingdoctors office visits. 
 
You have been asked to pay a $45 copayment for an in-network specialists office visit. This item/service falls 
within the Physician/Practitioner services, includingdoctors office visits 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 Plan called your providers office 
and the records show you had an appointment that day. Therefore, we decided that the Plan does not have to 
waive the copayment for an in-network specialists office visit provided on May 08, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve twelve (12) additional outpatient physical therapy (PT) visits for the enrollee.
You asked the Plan to pre-approve the therapy services. You say that it is medically necessary for the enrollee to receive additional PT visits. The Plan denied your request. The Plan says that that the enrollee does not meet criteria for additional PT visits.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for twelve (12) additional outpatient physical therapy (PT) visits. Our Medical Director states that the evidence submitted consists of a PT evaluation dated 4/18/2023. The listed diagnosis codes are: M54.40 (Lumbago with sciatica, unspecified), M54.16 (Radiculopathy, lumbar region), and R26.2 (Difficulty in walking, not elsewhere classified). The enrollee complained of exacerbation of lower back pain, radiating to the bilateral legs. The listed Onset Date is 4/17/2023. The pain level was documented to be 7-8/10. The Plan included manual therapy, therapeutic activities, and therapeutic exercise. The limited documentation submitted is insufficient to support the Plan's denial of 12 additional outpatient PT visits based on no improvement with therapy. Our Medical Director found that the enrollee's condition meets criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy services have been met. Therefore, we decided that the Plan has to pre-approve twelve (12) additional outpatient physical therapy (PT) visits for the enrollee.
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided on January 05, 2023, to January 
06, 2023. 
 
You asked the Plan to pay for the inpatient care. You say that the service was medically necessary. 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 inpatient care 
provided on January 05, 2023, to January 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manipulative treatment provided on March 01, 2023. 
 
You asked the Plan to pay for manipulative treatment. You say that you are appealing the claim payment 
denial. 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 manipulative treatment 
provided on March 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 20, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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 an office visit provided 
on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care services (99225) provided to the enrollee on June 1, 2022.
You asked the Plan to pay for the observation care services. You say that the services at issue have been billed correctly. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. Maximus overturned the Plan's denial for lack of information. The Plan requested a reopening and provided additional claim and payment documentation.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. However, such denials may be appealed. We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were reimbursed by the Plan on November 10, 2022. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the observation care services have not been met. Therefore, we decided that the Plan does not have to pay for the observation care services (99225) provided to the enrollee on June 1, 2022.