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

 
We decided that the Plan does not have to pay for the office visit, the therapeutic exercises and the mechanical 
traction therapy provided by a chiropractor on July 17, 2023, to July 20, 2023.  
 
You asked the Plan to pay for the office visit, the therapeutic exercises, and the mechanical traction therapy. 
You say that you contacted the provider office with your insurance information to make sure that the services 
were covered. you say that you did not make an appointment until you were assured the services were covered 
and would not have made the appointment if they were not covered. The Plan denied your request. The Plan 
says the only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit, the therapeutic exercises and the mechanical traction therapy 
provided by a chiropractor on July 17, 2023, to July 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 19, 2023, billed 
with codes 81433. 
 
You asked the Plan to pay for the genetic testing billed with procedure code 81433. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says panel testing 
should be billed using one CPT code on the claim. 
 
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 
September 19, 2023, billed with codes 81433.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) for the lower left quadrant 
provided on September 12, 2023.  

You asked the Plan to pay for the gingival irrigation for the lower left quadrant. You say that you still have 
$194 left for the annual allotment. You also say that this should be applied towards the procedures that have 
been denied. The Plan denied your request. The Plan says your benefit for this 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 this service was exhausted on date of service September 7, 2023. Therefore, we decided 
that the Plan does not have to pay for the gingival irrigation (D4921) for the lower left quadrant provided on 
September 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services rendered from February 1, 2022, to February 25, 2022.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says several items and services initially denied due to not having an itemized bill have now been identified as routine items and services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

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 denied services with denial code G on the itemized billed describe personnel; routine and disposable services, which would be included in the "room and board" charge. Additionally, the itemized bill includes vent management, initial day and vent management, subsequent day billed for the same date on February 1, 2022. This is incorrect duplicative billing.

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 inpatient hospital services rendered from February 1, 2022, to February 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate services. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says experimental and investigational procedures 
are not covered. 
 
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 the bone marrow aspirate services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that bone marrow aspirate is considered experimental/investigational for 
use as bone graft material and is not medically necessary. 
 
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 bone marrow aspirate services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve bone marrow aspirate services (20939).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
September 4, 2023, to September 16, 2023. 
 
You asked the Plan to pay for the SNF care. You say that the SNF care was medically necessary. The Plan 
denied your request. The Plan says the enrollee had already been covered for 100 days of SNF during the 
benefit period in question. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from July 27, 2023, to December 3, 2023. Specifically, coverage for SNF care provided from July 27, 2023, through August 17, 2023, 
from August 18, 2023, through September 3, 2023, and from October 4, 2023, through December 3, 2023. The 
Plan has covered 100 days of SNF care during this benefit period.  
 
Although the enrollee may have still needed skilled care, the Plan is not required to pay for more than 100 days 
of SNF coverage during this benefit period. Therefore, we decided that the Plan does not have to pay for the 
skilled nursing facility (SNF) care provided from September 4, 2023, to September 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D7250 x2) provided on August 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that this service was medically necessary. 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 August 23, 2023. Only 2 units of this service are covered per calendar year. Four were billed. Therefore, we decided that the Plan does 
not have to pay for dental services (D7250 x2) provided on August 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided January 2, 2023, to 
January 3, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care provided 
from January 2, 2023, to January 3, 2023, was medically necessary.  The Plan denied your request. The Plan says the inpatient hospital care provided from January 2, 2023, to January 3, 2023, was not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission it was reasonable for the admitting physician to expect that the enrollee's necessary hospital care 
(including earlier emergency department and/or observation care) would span two midnights with supporting 
documentation of the enrollees history and comorbidities, signs and symptoms, current medical needs, and risk 
of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided January 2, 2023, to January 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acute inpatient stay provided on June 12, 2023. 
 
You asked the Plan to pay for an acute inpatient stay. You say that this was medically necessary, please see 
records. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 acute inpatient stay provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint (SIJ) injection (27096) for the enrollee.

You asked the Plan to pre-approve a SIJ injection. You say that the enrollee had a positive Flexion Abduction
External Rotation (FABER) test on the right side, a positive thigh thrust test on the right side, and a positive
Yeoman's test on the right side. The Plan denied your request. The Plan says that the requested injection is not
medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a SIJ injection.
Our Medical Director states that the enrollee was evaluated on April 3, 2023, for constant dull aching in the
right gluteal region with intermittent sharp pain in the right gluteal region and right calf/foot. FABER,
Yeoman's, and thigh thrust testing were positive. The clinical documentation does not support that the
coverage criteria for an SIJ injection were met in this case. Our Medical Director found that the enrollee's
condition does not meet criteria for coverage of a SIJ injection.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a SIJ injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve a sacroiliac joint (SIJ) injection (27096) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a knee brace provided on September 29, 
2023. 
 
You asked the Plan to waive the coinsurance for a knee brace. You say that you could have bought it cheaper 
somewhere else. 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 20% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for a knee brace. This item/service falls within the prosthetic 
devices and related 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. The total you owe is $180 ($900 allowed amount x 20% = $180). Therefore, we decided 
that the Plan does not have to waive the coinsurance for a knee brace provided on September 29, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit (ER) and 
echocardiography (EKG) on March 27, 2023, to May 30, 2023.  
 
You asked the Plan to waive the copayment for the ER visit and EKG. 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). Your contract with the Plan clearly says that you must pay a $110 
copayment for each Medicare-covered emergency room visit (if you are admitted to the hospital within 24 
hours for the same condition, the copay will be waived). You must pay a 20% coinsurance for Medicare-
covered diagnostic tests (i.e., EKG). The provider billed in the amount of $2,138 and the allowed amount is 
$486.76. For the service it's $486.76 x 20% = $97.35. For both services it's $110 + $97.35 = $207.35. 
Therefore, results in the total cost sharing amount $207.35. 
 
You have been asked to pay a $110 copayment for the ER visit and a 20% coinsurance for EKG. This 
item/service falls within the emergency care and 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 waive the copayment for the emergency room visit 
(ER) and echocardiography (EKG) on March 27, 2023, to May 30, 2023.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided to the
enrollee from December 22, 2022, through December 31, 2022.

You asked the Plan to pay for the SNF care. You say that this should be covered by Medicare. The Plan denied
your request. The Plan says that the enrollee exhausted the 100 days of the SNF benefit. Maximus overturned
the Plan's denial based on a lack of information. The Plan requested a reopening and states that they have
provided coverage for 100 days of SNF care for this benefit period. The Plan is correct in this case. The file
shows that the enrollee received 100 days of SNF care during the benefit period from August 18, 2022, through
September 2, 2022, October 3, 2022, through October 12, 2022, October 26, 2022, through November 3, 2022,
November 24, 2022, through December 21, 2022, and January 3, 2023, through February 13, 2023. The Plan
has covered 100 days of SNF care.

Although the enrollee may still have needed skilled care, the Plan is not required to pay for more than 100 days
of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the
enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore,
we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided to the
enrollee from December 22, 2022, through December 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and panoramic x-ray 
(D0330) provided on September 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told by the front desk at the dentist 
and by a representative with the Plan that the Plan was in-network. You also say that almost two weeks after 
your visit, you received a letter in the mail stating you are responsible for $295 because one certain dentist that 
you were put with was not in-network. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental 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. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on September 25, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
September 7, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel rendered on September 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the practitioner services provided to the enrollee from
January 2, 2023, through January 11, 2023.

You asked the Plan to pay for the practitioner services. You say that the claim is billed correctly and should be
paid. The Plan denied your request. The Plan says that the claim was billed incorrectly. Maximus overturned
the Plan's denial. The Plan requested a reopening and states that the date of the last Kt/V reading was not
during the billing period. The Plan is correct in this case. Medicare rules say occurrence code 51 is the date of
the last Kt/V reading and for in-center hemodialysis patients this is the date of the last reading taken during the
billing period. The claim provided shows a Kt/V reading date of January 25, 2023. This is not during the billing
period from January 2, 2023, through January 11, 2023. Therefore, we decided that the Plan does not have to
pay for the practitioner services provided to the enrollee from January 2, 2023, through January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - periapical first x-ray (D0220) provided on September 11, 2023.

You asked the Plan to pay for intraoral - periapical first x-ray. You say that you called and spoke to a Plan rep, who told you that this provider was under your Plan. The Plan denied your request. The Plan says this is not a covered service.

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 intraoral - periapical first x-ray (D0220) provided on September 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an endoskeletal knee-shin system (L5828,
L5845, L5848, and L5850).

You asked the Plan to provide coverage for this prosthetic equipment for the enrollee. You say that at the time
of the appeal, this equipment was 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 the medical records do not show why a mechanical K3 knee cannot be used for the enrollee's
initial K3 prosthesis, given the weight of a microprocessor knee and the enrollee's co-morbidities. The records
do not show why a mechanical knee, which is more durable, and less prone to damage and corrosion, will not
meet enrollee's needs.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. The medical records provided do not clearly show
why it is medically necessary for the enrollee to have a microprocessor knee. Medicare rules for coverage of
this prosthetic equipment for the enrollee have not been met. Therefore, we decided that the Plan does not have
to provide coverage for an endoskeletal knee-shin system (L5828, L5845, L5848, and L5850).