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

We decided that the Plan does not have to pay for the acute inpatient hospital care provided to the enrollee
from July 21, 2022, to July 23, 2022.

You asked the Plan to pay for acute inpatient hospital care. You say that this claim should be paid. The Plan
denied your request. The Plan says the Medicare coverage criteria were not met. Maximus upheld the Plans
denial for no authorization for out of network services. However, it was determined after the decision was
made that this case should have been reviewed for medical necessity.

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. Based on the medical records provided, the enrollee was stable after the emergency department course of
treatment and reported to be at baseline. Imaging studies were normal. The enrollee was a concern for falls and
skilled nursing facility services were sought. However, the medical records show no direct indication from the
treating physician that the enrollees' conditions were such that an inpatient course of care spanning two
midnights was required to further diagnose treatment and/or provide stabilization of systems. 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 to the enrollee from July 21, 2022, to July 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is medically stable for discharge to continue 
home medications, does not require complex wound care and has no other active/acute problems. The Plan says 
the enrollee has no current needs that can only be provided on an inpatient basis. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee currently has a wound vac on that is changed twice weekly, on oral 
antibiotics and an oral anti-fungal. The enrollee does not require ventilator weaning, has non-complex wound care, and does not require >=6.5 hours per day of skilled nursing care. Te enrollee does not meet LTACH 
admission criteria. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on July 
11, 2023, to July 17, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. 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 $325 
copayment for Inpatient services in a psychiatric hospital. 
 
You have been asked to pay a $325 copayment for the inpatient hospital stay. This item/service falls within the 
Inpatient services in a psychiatric hospital 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 $975 ($325 copayment x 3 days). You were not charged 
for days 4-6. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient 
hospital stay provided on July 11, 2023, to July 17, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 81479 billed for date of service September 1, 2023. 
 
You asked the Plan to pay for the billed code. You say that this is a Medicare covered service. The Plan denied 
your request. The Plan says that code 81479 does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT code 81479 is supported. The Local Coverage Article for the Guardant360 test does show 
that code 81479 is able to be billed for this test. Based on this information, we decided that Medicare rules for 
coverage of the billed code have been met. Therefore, we decided that the Plan has to pay for procedure code 
81479 billed for date of service September 1, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chest x-ray (71046) and abdominal 
untrasound (76770) provided on August 09, 2023, to September 07, 2023. 
 
You asked the Plan to waive the copayment for the chest x-ray (71046) and abdominal untrasound (76770). 
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 $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $50 copayment for the chest x-ray (71046) and abdominal untrasound (76770). 
This item/service falls within the 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. You were 
charged $50 for each diagnostic service. Therefore, we decided that the Plan does not have to waive the 
copayment for the chest x-ray (71046) and abdominal untrasound (76770) provided on August 09, 2023, to 
September 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on October 31, 2022, to 
November 2, 2022, billed with procedure code 99233. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the level of care is not supported 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
We asked our physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the provided documentation did not 
describe detailed history and described the enrollee as off sedation with ongoing vent support and 
encephalopathy with minimal changes in treatment describing medical decision-making of moderate 
complexity, not high complexity. Therefore, based on the documentation, the criteria are not met for the code, 
99233 for the above dates. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on October 31, 2022, to November 2, 2022, 
billed with procedure code 99233.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on September 
22, 2023. 
 
You asked the Plan to pay for chronic care management services. You say that you are appealing the denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chronic care 
management services provided on September 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the complex imaging provided on April 24, 
2023, to April 27, 2023. 
 
You asked the Plan to waive the copayment for the complex imaging. You say that you were unaware of the 
changes made to your benefits. 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 $300 
copayment for outpatient diagnostic tests, including complex imaging. 
 
You have been asked to pay a $300 copayment for the complex imaging. This item/service falls within the 
outpatient diagnostic tests, including complex imaging 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 a $300 copayment for the 
nuclear medicine study on April 24, 2023. You have also been asked to pay $244.55, which is less than the 
standard copayment for the computed tomography scan on April 27, 2023. Therefore, we decided that the Plan 
does not have to waive the copayment for the complex imaging provided on April 24, 2023, to April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the surgical extraction of tooth #3, 20, 21, and 28 (D7210). 
 
You asked the Plan to pre-approve the surgical extractions. You say that you are requesting reconsideration of 
the denied services as this is not a duplicate request. You also say that you requested that the requested 
extractions are not down coded. The Plan denied your request. The Plan says that the surgical extractions of the 
requested teeth are not medically necessary. The Plan also says that simple extractions of the requested teeth 
are pre-approved. 
 
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 Plan covers the surgical 
extractions when the services are medically necessary and reasonable. 
 
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 surgical extractions. Our reviewer 
says that the surgical extractions are medically necessary for the enrollee. Our physician reviewer found that 
due to the severe decay noted on these teeth, it is medically reasonable for teeth #3, 20, 21, and 28 to be 
surgically extracted. When teeth are broken down and only roots remain, or the decay is so large, bone may 
need to be removed, or the tooth cut into pieces to remove the tooth completely. When a tooth is severely 
decayed, force applied with extraction forceps will cause the tooth to further crumble. In this situation, bone 
needs to be removed to access tooth structure that is not decayed so that force can be applied to remove the 
tooth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the surgical extractions have been met. Therefore, we decided that the Plan has 
to pre-approve the surgical extraction of tooth #3, 20, 21, and 28 (D7210).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 9, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 99100 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 code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87640, 87651, and 87641 billed for 
date of service August 16, 2023. 
 
You asked the Plan to pay for procedure codes 87798, 87640, 87651, and 87641. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says payment for codes 87798, 87640, 87651, 
and 87641 is bundled into payment for code 87801. 
 
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 codes 87798, 87640, 87651, and 87641 are column II codes to column I 
code 87801. While codes 87798, 87640, 87651, and 87641 were billed with modifier -59, the medical records 
provided do not show that the service billed with the -59 modifier is a distinct procedural service. 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 codes 87798, 87640, 87651, and 87641 billed for date of service August 16, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 71046, 93005, 93041, and 96372 provided 
on August 16, 2023. 
 
You asked the Plan to pay for procedure codes 71046, 93005, 93041, and 96372. You say that these services 
were medically necessary. The Plan denied your request. The Plan says the codes billed are not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that services with status indicator N are paid under 
the Outpatient Prospective Payment System (OPPS), but their payment is packaged into payment for a 
separately paid service. 
 We find that CPT code 71046, 93005, 93041, and 96372 is not supported in the medical record. Specifically, 
these codes have a status indicator of N and payment is packaged with payment for another service. Based on 
this information, we decided that Medicare rules for coverage of procedure codes 71046, 93005, 93041, and 
96372 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 71046, 
93005, 93041, and 96372 provided on August 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service September 13, 
2023. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says one code must be 
submitted for the panel. The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
The file shows that the panel testing was billed using codes 87481, 87500, 87640, 87653, and 87798. We 
looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe 
technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were used in 
this case. As such, a single code with one unit of service should be used. Based on this information, we decided 
that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the panel testing billed for date of service September 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit for assessment and 
management ofa patient (G0463) provided on August 25, 2023. 
 
You asked the Plan to pay for the hospital outpatient clinic visit for assessment and management ofa patient 
(G0463). You say that the service was medically necessary. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the hospital outpatient 
clinic visit for assessment and management ofa patient (G0463) provided on August 25, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
Plan's required drugs, Retacrit or Procrit. The records do not show that the Aranesp is being requested for a 
medically accepted indication. The required drugs would not be contraindicated or less effective; therefore, 
Aranesp is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx (0239U) provided on March 
16, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that you are writing to request the claim of the 
FoundationOne Liquid CDx comprehensive genomic profiling test, be reconsidered. The Plan denied your 
request. The Plan says the medical necessity criteria has not been met. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing have been met. 
Additional records was requested from the provider to determine medical necessity. The records show that the 
Plan made multiple attempts to obtain the additional record from the provider without success.. Therefore, we 
decided that the Plan does not have to pay for the FoundationOne Liquid CDx (0239U) provided on March 16, 
2023, by an out-of-network (OON) provider.