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

We decided that the Plan does not have to pay for the chest x-ray (71045) provided to the enrollee on June 21, 2022.
You asked the Plan to pay for the chest x-ray. You say that the claim denied in error. 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. The Plan requested a reopening and provided evidence of a paid claim for the chest x-ray.
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 July 13, 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 chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045) provided to the enrollee on June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on August 20, 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 this claim must be addressed by the enrollee's primary payor at the time of service. Maximus overturned the Plans denial. The Plan requested a reopen and demonstrated that they must have the Primary Explanation of Benefits (EOB) before payment is rendered. The Medicare beneficiary data base shows the enrollee had primary insurance with another carrier at the time of service. The Plan made several outreach attempts to the provider, the enrollee and the primary carrier for assistance in obtaining the primary EOB, without any success.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance.
This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has attempted several options in obtaining proof the primary addressed this claim appropriately. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on August 20, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on September 16, 2022 and billed under code 76641.
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 billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that per the Medicare guidelines effective July 1, 2022, code 76641 has a medically unlikely edit (MUE) value of 1 and an MUE Adjudication Indication (MAI) of 2 indicating this is a date of service edit. The MUE value for this code changed from 2 to 1 as of July 1, 2022. Since the date of service was September 16, 2022, the new MUE value of 1 would apply.
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, this claim could not be paid due to an error with the MUE edit for code 76641.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on September 16, 2022, and billed under code 76641.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you cannot walk on your own and are not ready to
return home. The Plan denied your request. The Plan says that the request is not medically necessary. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for continued SNF
care. Our Medical Director states that there is no documentation that you require the services on an inpatient
basis, only in a skilled nursing facility setting. Records support that services in the home with home health care
or in a long-term care facility on a part time basis are appropriate in this case. Our physician reviewer found
that the enrollee's condition does not meet Medicare criteria for continued SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6222 and A6219 billed for date of service 
November 30, 2022. 
 
You asked the Plan to pay for procedure codes A6222 and A6219. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says procedure code A6222 and A6219 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes A6222 and A6219 have a status indicator of P on the Physician Fee Schedule. 
This means that no separate payment is made for procedure codes A6222 and A6219 under the fee schedule. 
Based on this information, we decided that Medicare rules for coverage of procedure codes A6222 and A6219 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A6222 and 
A6219 billed for date of service November 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the specialist office visit and laboratory 
services provided on January 4, 2023. 
 
You asked the Plan to waive the coinsurance for the specialist office visit and lab services. You say that you 
have never had to pay over $45 for this appointment 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 40% 
coinsurance for out-of-network specialist office visits. Your contract with the Plan also clearly says that you must pay 40% coinsurance for out-of-network lab services. 
 
You have been asked to pay 40% coinsurance for the specialist office visit. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay 40% coinsurance for each lab 
service. These items/services fall within the outpatient diagnostic tests and therapeutic services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for the specialist office visit and laboratory 
services provided on January 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anendoscopy provided on October 13, 2022. 
 
You asked the Plan to pay for anendoscopy. You say that the services 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 anendoscopy provided 
on October 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic and retainer crown (D6245, D6740). 
 
You asked the Plan to pre-approve 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 pre-approve a 
pontic and retainer crown (D6245, D6740).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for pulmonary ventilation and perfusion 
imaging provided on December 05, 2022. 
 
You asked the Plan to reduce the copayment for pulmonary ventilation and perfusion imaging. You say that 
you were told you would only have a $50 copayment. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $225 copayment for pulmonary ventilation and perfusion imaging. This item/service falls within the in-network outpatient diagnostic tests and therapeutic services and supplies 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 reduce the copayment for pulmonary ventilation and perfusion imaging 
provided on December 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 31, 2022. 
 
You asked the Plan to pay for an office visit. You say that this 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 an office visit provided 
on October 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 19, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 19, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service July 28, 
2022. 
 You asked the Plan to pay for procedure code 81345. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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, we have confirmed that code 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81345 billed for date of service July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99223) provided on June 28, 2022. 
 
You asked the Plan to pay for the hospital care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is This initial hospital care evaluation and 
management code requires a comprehensive history, a comprehensive examination and medical decision 
making of high complexity. 
 
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 hospital care. Our reviewer says that the billed code is 
not supported. Our reviewer found the records do not support medical decision making of high complexity.  
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 hospital care have not been met. Therefore, we decided that the Plan does 
not have to pay for hospital care (99223) provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 06, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services were 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 an office visit provided 
on September 06, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that at the time of the appeal, SNF services were medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the anemia, chronic obstructive pulmonary disease, and diabetes are documented as stable. There were no daily skilled nursing service needs at the time of the appeal. There have been three stays in rehabilitation which have not changed your level of function. At the time of the appeal your previous level of function was non ambulatory needing a Hoyer-lift for transfers. You were moderate assist for activities of daily living, and the current level of function is documented as the same.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. Based on the medical records provided, your care needs were custodial in nature. The records do not show you required daily skilled nursing and/or daily skilled therapy services at an inpatient level of care. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 01, 2022. 
 
You asked the Plan to pay for an office visit. You say that you think that this provider is in-network. 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 June 01, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
January 21, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you had to be transferred 
because the initial location could not provide the services you needed. 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 $255 
copayment for one-way ambulance services. 
 
You have been asked to pay a $255 copayment for the ambulance services. This item/service falls within the 
one-way ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance services provided on January 21, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 17, 2021. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the claim needs to be reprocessed. 
The Plan denied your request. The Plan says the claim was denied as timely filing. 
   
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for subsequent nursing facility care was not filed until January 18, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on April 
17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 12, 2023. 
 
You asked the Plan to pay for office visit. You say that you were unaware that your contract did not include the 
health plan. 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 office visit provided on 
January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment and abutment supported 
porcelain/ceramic crown (D6057, D6058). 
 
You asked the Plan to pre-approve 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 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 January 19, 2023 to July 
9, 2023. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment and 
abutment supported porcelain/ceramic crown (D6057, D6058).