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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 18, 2022, 
through November 22, 2022, and billed with diagnosis code N170. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis N17.0 is supported by the records. The Plan denied your request. The Plan says the documentation 
submitted does not support primary diagnosis of N17.0 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code N170 -Acute kidney failure 
with tubular necrosis. 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 the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support the primary 
diagnosis of N170-Acute kidney failure with tubular necrosis. Our physician reviewer found the member was 
hospitalized with an ileus and poor oral intake. The laboratory studies showed prerenal azotemia, which 
responded to intravenous ceftriaxone fluids, in the setting of chronic kidney disease. There is no evidence of 
renal ischemia or tubular necrosis. As such, the billing of N17.0 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 18, 2022, through November 22, 2022, and billed with 
diagnosis code N170.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided to the enrollee on March 28, 2022.
You asked the Plan to pay for the pathology services. You say that these services were medically necessary. The Plan denied your request. The Plan says Original Medicare is responsible for payment. Maximus overturned the Plan's denial. The Plan requested reopening and provided proof of the enrollee's hospice enrollment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on March 19, 2022. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the pathology services provided to the enrollee on March 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the chest x-ray provided on February 3, 
2023. 
 
You asked the Plan to waive the deductible for the chest x-ray. You say that these services should all be 
covered. 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 $625 deductible which applies to in-network outpatient diagnostic 
tests and therapeutic services.  
 
You have been asked to pay $146.34 towards the deductible. The item or service you asked the Plan to waive 
the deductible for falls within the in-network outpatient diagnostic tests and therapeutic services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $625 deductible which applies to in-network outpatient diagnostic tests and therapeutic services. This cost sharing is 
a contractual obligation that had not been met at the time the chest x-ray was received on February 3, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the chest x-ray provided on 
February 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional retainer crown (D6790). 
 
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 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 when the Plan overturned the denial of 1 
retainer crown (D6750), this approval resulted in your benefit exhausting. Therefore, we decided that the Plan 
does not have to pre-approve the additional retainer crown (D6790).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF care was medically necessary. The Plan denied your request. The Plan says 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.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF services.
The medical records show the enrollee was a then 49-year-old woman with a medical history that included previous reconstructive procedures of the left foot and metallic ankle implant as well as total talus. The enrollee developed chronic osteomyelitis of the left heel. On December 7, 2022, left below-knee amputation was performed. The enrollee had post-operative anemia. HgA1c was elevated at 6%. It was noted that the enrollee did not require inpatient admission. "Anemia is present and is being monitored. Patient is requiring minimal assistance of tow for all mobility and minimal-total assistance for ADL's." The Plan is correct in this case. The documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on October 18, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for 
the comprehensive oral evaluation 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 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 comprehensive oral evaluation was exhausted on date of service March 1, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or 
established patient (D0150) provided on October 18, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded as 88237, 88264, 88271, and 88275 provided on September 29, 2021.
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 provided additional information.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that the codes that support medical necessity for cytogenetic studies are C91.10 for Chronic lymphocytic leukemia of B-cell type not having achieved remission and C91.12 for Chronic lymphocytic leukemia of B-cell type in relapse. The diagnosis code billed was C90.00 for multiple myeloma without remission. This is not a code listed as covered in the applicable coverage rules. Therefore, we decided that the Plan does not have to pay for the laboratory services coded as 88237, 88264, 88271, and 88275 provided on September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the FreeStyle Libre 14-day sensor (Current Procedural Terminology (CPT) code A4239) for the enrollee.
You asked the Plan to provide coverage for this equipment. You say that at the time of the appeal, this equipment was medically necessary for the enrollee. The Plan denied your request. The Plan says all of the required Medicare coverage criteria were not met. Maximus overturned the Plans denial stating the equipment would be beneficial for the enrollee due to her dementia. The Plan requested a reopen and stated that the LCD is clear that all required criteria must be met for this equipment to be approved.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The medical records provided do not clearly show the enrollee meets all of the required LCD criteria. Social issues with the use of typical equipment is not a reason to supersede the required Medicare criteria. Medicare rules for coverage of this equipment have not been met. Therefore, we decided that the Plan does not have to provide coverage for the FreeStyle Libre 14-day sensor (Current Procedural Terminology (CPT) code A4239) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided the Plan does not have to pay for code 76641 billed for date of service September 6, 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 the Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that per the Medicare MUE Practitioner Services sheet Effective July 1, 2022, code 76641 has an MUE value of 1, and an MUE Adjudication Indicator (MAI) of 2. The MUE value for code 76641 changed from 2 to 1, as of the July 1, 2022 update. As the date of service in question is September 6, 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. Providers must report services with the appropriate codes. In this case, this claim could not be paid as billed due to an error with MUE value. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 6, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for code 78815 billed for date of service January 13, 2022.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this code is included in the payment of code 78816 billed and paid on a previous claim for the same date of service. Maximus overturned the Plans denial as the paid claim was not included in the case file. The Plan requested a reopen and provided the paid claim.
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, this claim could not be paid as billed as the payment for code 77815 is included in the payment for code 78816 per the Medicare guidelines. Therefore, we decided that the Plan does not have to pay for code 78815 billed for date of service January 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immediate maxillary and mandibular dentures (D5140, 
D5130) provided on April 19, 2022, to September 26, 2022. 
 
You asked the Plan to pay for 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 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 pay for 
immediate maxillary and mandibular dentures (D5140, D5130) provided on April 19, 2022, to September 26, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88377, and 88381 
billed for date of service June 17, 2020. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, 88377, and 88381. You say that the 
services are payable. The Plan denied your request. The Plan says the codes are included in the facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 88377, and 
88381. This means there is both a professional and technical component for the CPT codes. In this case, an 
appropriate modifier to indicate the professional component has not been billed with the CPT codes. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88377, and 88381 billed for date of 
service June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two crowns (D2740) provided on September 14, 2022.
You asked the Plan to pay for both crowns. We note the Plan paid for one crown based on the Plan contract agreement. You say that these crowns should be covered by the Plan. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plans denial stating one crown should be covered. The Plan requested a reopen and stated one crown was covered and one crown was denied. The Plan noted that Maximus did not address the second crown.
The Plan is correct in this case. 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. The Plan covers one crown per year. You were provided with two crowns. The Plan paid for one crown and denied the second as exceeding the dental benefit. Therefore, we decided that the Plan does not have to pay for two crowns (D2740) provided on September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220) x2, 
intraoral - periapical each additional radiographic image (D0230) x2 and endodontic therapy, anterior tooth 
(excluding final restoration) (D3310) provided on November 15, 2022, and December 15, 2022. You also 
asked the Plan to pay more for endodontic therapy, premolar tooth (excluding final restoration) provided on 
December 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that your claim should be covered 100% by your 
insurance. 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. Enrollees must pay 70% 
coinsurance for covered in-network dental services. This benefit includes the requested intraoral - periapical 
first radiographic image and intraoral - periapical each additional radiographic image but is limited to one 
procedure code per calendar year and endodontic therapy, anterior tooth (excluding final restoration) but is 
limited to one per calendar year. 
 
You have been asked to pay $892.50, which is 70% of the allowed amount for the endodontic therapy, 
premolar tooth (excluding final restoration). The allowed amount is $1,275 (70% x $1,275 = $892.50). This 
service falls within the major dental services provided in-network 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 
pay more for endodontic therapy, premolar tooth (excluding final restoration) provided on December 15, 2022. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered intraoral - periapical each additional radiographic image (D0230) on October 4, 
2022. You also received covered endodontic therapy, anterior tooth (excluding final restoration) (D3310) on 
December 15, 2022. Therefore, these benefits were exhausted as of November 15, 2022, and December 15, 
2022. Therefore, we decided that the Plan does not have to pay for intraoral - periapical first radiographic 
image (D0220) x2, intraoral - periapical each additional radiographic image (D0230) x2 and endodontic 
therapy, anterior tooth (excluding final restoration) (D3310) provided on November 15, 2022, and December 
15, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 1, 2022.
You asked the Plan to pay for procedure code 76642. You say that the claim has been coded correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, a respiratory flow volume loop and 
pulmonary stress testing provided on November 10, 2022.  

You asked the Plan to pay for an office visit, a respiratory flow volume loop and pulmonary stress testing. You say that the Provider was not a part of the enrollee's hospice team of doctors. The Plan denied your request. The Plan says Original Medicare is responsible for payment 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an office visit, a respiratory flow volume loop and pulmonary 
stress testing provided on November 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate (20939). You say that the requested bone marrow 
aspirate is medically necessary. The Plan denied your request. The Plan says the requested bone marrow 
aspirate is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 bone marrow aspirate (20939). Our 
reviewer says that the requested bone marrow aspirate is not medically necessary. Our physician reviewer 
found bone marrow aspirate is experimental when used as bone graft material. More research is needed at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate (20939) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 6, 2022.
You asked the Plan to pay for procedure code 76641. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 6, 2022.