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

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided on 
May 10, 2023, to May 16, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the cost share is 
wrong. 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 $350 
copayment for inpatient hospital services. 
 
You have been asked to pay a $350 copayment for the inpatient hospital services. This item/service falls within 
the inpatient hospital 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. You were charged $1,750 ($350 X 5 days). You were not charged for day 6. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital services provided on May 
10, 2023, to May 16, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the supply allowance for non-adjunctive, non-implanted continuous 
glucose monitor provided on September 17, 2023. 
 
You asked the Plan to pay for the supply allowance for non-adjunctive, non-implanted continuous glucose 
monitor. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says that the 
documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid physician order and proof of delivery. Review of the file does not reveal any 
reason that the required documentation is invalid. In addition, the documentation does not include an 
explanation on why these items should not be covered. Therefore, we decided that the Plan has to pay for the 
supply allowance for non-adjunctive, non-implanted continuous glucose monitor provided on September 17, 
2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the inpatient hospital care provided by an 
in-network provider from May 8, 2023, to May 13, 2023. 
 
You asked the Plan to waive the cost sharing for the inpatient hospital care. You say that you already met your 
maximum out-of-pocket. 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 that there is a $800 
deductible which applies to inpatient hospital care, and that you must pay a 10% coinsurance of the approved 
amount for in and out-of-network inpatient hospital care. 
 You have been asked to pay up to a 10% coinsurance of the allowed amount for the inpatient hospital care after 
the deductible had been met, and the deductible was satisfied during the processing of the claims. These 
items/services fall within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
cost sharing for the inpatient hospital care provided by an in-network provider from May 8, 2023, to May 13, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit provided on June 21, 2023. 
 
You asked the Plan to waive the cost share for an office visit. You say that you were told you would not be 
charged for the visit. 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 doctor and other health care 
provider services. Your contract with the Plan clearly says that you must pay 10% coinsurance of the allowed 
amount for provider services.  
You have been asked to pay $10.86, which is 10% coinsurance of the allowed amount for the office visit. 
($108.58 allowed amount x 10% = $10.86). The remaining allowed amount is $97.72 ($108.58 allowed amount 
- $10.86 coinsurance = $97.72). This item/service falls within the doctor and other health care provider 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. 
 
You have been asked to pay $97.72 towards the deductible for the office visit. The item or service 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 doctor and other health care provider services. This cost sharing is a contractual 
obligation that had not been met at the time an office visit was received on June 21, 2023. Therefore, we 
decided that the Plan does not have to waive the cost share for an office visit provided on June 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is not at their baseline and their wife is 
not able to care for them at home in their condition. Going to acute rehab will be most beneficial to the enrollee 
and their goals of care. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for codes 87481, 87500, 87511, 87640, 87653, 87798 and
87801 billed to the enrollee for date of service February 8, 2023.

You asked the Plan to pay this claim. You say that these services should be paid by the Plan. The Plan denied
your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial.
The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted
that the laboratory services were incorrectly coded.

The Plan notes this was an Mol Dx panel. A "Not Otherwise Classified" (NOC) code should billed with one
unit of service and not unbundled with -59 modifiers. A test panel cannot be unbundled and billed as individual
components although the test reports multiple individual pathogens and/or targets. The billing laboratory did
not include any medical records with the claim or the reconsideration request. The services billed with the -59
modifier were reviewed and denied as the services were included and were not separate and distinct services.
The Plan indicates they notified the billing laboratory of the denial for the claim on February 17, 2023, and the
provider was informed that the codes billed were incorrect and there was a more appropriate NOC code that
should be billed.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to
determine whether payment is due and the amount of payment. Medicare requires providers to report services
correctly. Based on the medical records and the claim submitted, there is insufficient information in the record
to determine if Medicare rules for payment of this claim have been met. Therefore, we decided that the Plan
does not have to pay for codes 87481, 87500, 87511, 87640, 87653, 87798 and 87801 billed to the enrollee for
date of service February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 25, 2023, billed 
with procedure code 64447-59. 
 
You asked the Plan to pay for practitioner services. You say that the claim is billed correctly. The Plan denied 
your request. The Plan says code 64447-59 is not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for practitioner services. Our reviewer says that 
the service does not meet criteria for billing or reimbursement consideration. Our physician reviewer found 
Current Procedural Terminology (CPT) 64447 has a bundled relationship to CPT 01402, which was also 
performed on January 25, 2023. The medical records provided does not include sufficient documentation to 
validate unbundling 64447 from 01402 with the use of a 59 modifier, therefore this procedure cannot be 
verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of practitioner services have not been met. Therefore, we decided that the Plan 
does not have to pay for practitioner services provided on January 25, 2023, billed with procedure code 64447-
59.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied IRF services and that the services requested are medically necessary. The Plan denied your request. The 
Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for 
approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for inpatient hospital care provided on July 23, 
2023, to July 26, 2023. 
 
You asked the Plan to waive the cost share for inpatient hospital care. You say that you disagree with the cost 
share. 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 $500 deductible and a 10% coinsurance which applies to inpatient 
hospital care.  
 
The item or service you asked the Plan to waive the cost share for falls within the inpatient hospital care benefit 
category. You are being asked to pay $150 towards your deductible. You are also being asked to pay $137.79 
towards your copayment. Also being asked to pay $350 towards your coinsurance. The total amount you are 
being asked to pay is $637.79 ($150 + $350 + $137.79 = $637.79). The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $500 deductible and a 10% coinsurance which applies to 
inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time inpatient hospital care was received on July 23, 2023, to July 26, 2023. Therefore, we decided that the Plan does not 
have to waive the cost share for inpatient hospital care provided on July 23, 2023, to July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5225) and a lower partial
denture (D5226).

You asked the Plan to pre-approve an upper partial denture and a lower partial denture. You say that you are
requesting a reconsideration of the Plan's denial. 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 because of a
lack of information. The Plan requested a reopening and stated that you have already used your benefit for this
service. The Plan is correct 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 December 7, 2020. Therefore, we decided that the Plan does not have to preapprove
an upper partial denture (D5225) and a lower partial denture (D5226).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on March 15, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the Cxbladder test (0012M) provided on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic care (99202, 98941) provided on March 30, 
2023, to May 17, 2023. 
 
You asked the Plan to pay for the chiropractic care (99202, 98941). 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 the chiropractic care 
(99202, 98941) provided on March 30, 2023, to May 17, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the peripheral nerve block injections described by codes 64450 and 
64447 performed on date of service June 28, 2023. 
 
You asked the Plan to pay for 64450 and 64447. You say that 64450 and 64447 should be paid as billed 
because they are supported in the documentation and modifier -59 was appended to both codes. The Plan 
denied your request. The Plan says that 64450 and 64447 are denied because records dont support these 
services were performed for postoperative pain management. 
 
The Plan must follow Medicare rules. Medicare rules say that a peripheral nerve block injection for 
postoperative pain management can be reported separately on the same date of service as an anesthesia 
0XXXX code with modifier -59 or -XU appended to indicate it was administered for postoperative pain 
management. 
 
We looked at the file and Medicare rules. In this case, we confirmed that 64450 and 64447 were reported on 
the same day as anesthesia code 01402. We confirmed 64450 and 64447 were both billed with modifier -59. 
The records clearly document that the nerve block injections coded as 64450 and 64447 were intended for 
postoperative pain management and were requested by the surgeon. There is no evidence in the record that they 
were performed preoperatively. There is no evidence in the record that they were used as the primary anesthetic 
technique or as a supplement to the primary anesthetic technique. Based on this information, we decided that 
Medicare rules for coverage of 64450 and 64447 have been met. Therefore, we decided that the Plan has to pay 
for the peripheral nerve block injections described by codes 64450 and 64447 performed on date of service 
June 28, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87481, 87500, 87511, 87640, 87653,
87798 and 87801) provided to the enrollee on February 7, 2023.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and noted that Maximus did not apply the correct billing criteria.

The Plan noted that the laboratory services were incorrectly coded and not in accordance with Medicare
guidelines. This was a Mol Dx panel and a "not otherwise classified" (NOC) code should billed with one unit
of service and not unbundled with -59 modifiers. A test panel cannot be unbundled and billed as individual
components although the test reports multiple individual pathogens and/or targets. The billing laboratory did
not include any medical records with the claim or the reconsideration request. The services billed with the -59
modifier were reviewed and denied as the services were included and were not separate and distinct services.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to
determine whether payment is due and the amount of payment. There are insufficient medical records provided
to support this claim as billed. There are errors on the claim that have been identified by the Plan with
suggestion of correction. Therefore, we decided that the Plan does not have to pay for laboratory services
(87481, 87500, 87511, 87640, 87653, 87798 and 87801) provided to the enrollee on February 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on May 23, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the Cxbladder test (0012M) provided on May 23, 2023.