Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on February 16, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that you are requesting reconsideration of the denied 
claim. 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 psychotherapy 
provided on February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye visit with a diagnostic procedure provided on July 06, 
2023. 
 
You asked the Plan to pay for an eye visit with a diagnostic procedure. You say that you were unaware that this 
provider was out-of-network, or that this procedure would need a prior authorization. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an eye visit with a 
diagnostic procedure provided on July 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99239 billed for date of service June 20. 2022. 
 
You asked the Plan to pay for code 99239. You say that you have provided medical records supporting 
payment. The Plan denied your request. The Plan says the code at issue 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 99239 is Hospital discharge day management: more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the code definition is time-
based, and the records submitted for review do not document the total time spent providing the services 
described by this code. Based on this information, we decided that Medicare rules for coverage of code 99239 
have not been met. Therefore, we decided that the Plan does not have to pay for code 99239 billed for date of 
service June 20. 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on March 
9, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on March 9, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on August 02, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you do not think you should be 
billed for this 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for in-network services received from a level 1 specialist physician. 
 
You have been asked to pay a $30 copayment for an office visit. This item/service falls within the in-network 
services received from a level 1 specialist physician 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 an office visit provided on August 02, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on May 18, 2023. 
 
You asked the Plan to pay for the CxBladder testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0012M for CxBladder is non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the service at issue was the CxBladder 
coded 0012M. This service is specifically not covered. Based on this information, we decided that Medicare 
rules for coverage of the CxBladder testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the CxBladder testing provided on May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99232 and 99239 rendered on June 26, 
2023, to June 29, 2023. 
 
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 the denied codes remain 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 the denied codes is: 
 
CPT 99232: 
 
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision 
making. When using total time on the date of the encounter for code selection, 35 minutes must be met or 
exceeded 
 
CPT 99239: 
 
Hospital inpatient or observation discharge day management; more than 30 minutes on the date of the 
encounter 
 
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 documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of moderate level, or that 35 
minutes were spent, so code 99232 is not warranted. Additionally, in terms of CPT 99239, the documentation 
does not support that 30 minutes or more were spent on discharge day management. 
 
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 procedure codes 99232 and 99239 rendered on June 26, 2023, to June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS cytopathology and histopathology diagnostic 
testing provided on March 15, 2023.  
You asked the Plan to pay for the WATS cytopathology and histopathology diagnostic testing. You say that 
this testing was medically necessary. The Plan denied your request. The Plan says screening for Barrett's 
esophagus is not a covered screening service. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the WATS cytopathology and histopathology diagnostic testing, was requested 
solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we 
decided that the Plan does not have to pay for the WATS cytopathology and histopathology diagnostic testing 
provided on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the room and board (0120) and records fee (0229), provided 
August 15, 2023, to August 26, 2023.   

You asked the Plan to pay for the room and board and records fee. You say that the services should be covered. 
The Plan denied your request. The Plan says proof of payment was not submitted for room and board and 
records fee is a non covered service as it is not a medical service. 
 
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 room and board and records fee 
have been met. There was no proof of payment submitted for the room and board charge.. Therefore, we 
decided that the Plan does not have to pay for the room and board (0120) and records fee (0229), provided 
August 15, 2023, to August 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tiedown contour seat (K0108). 
 
You asked the Plan to pre-approve a tiedown contour seat. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item does not serve a 
medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a tiedown contour seat (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing billed with codes 81408, 81407, 81170, 
81406, 81405, and 81401 for date of service June 9, 2023. 
 
You asked the Plan to pay for the genetic testing billed with codes 81408, 81407, 81170, 81406, 81405, and 
81401. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays 2 or more genes in a patient 
in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single 
procedural service, so 1 HCPCS codes must be submitted for the panel.  
 
 
 
 We looked at the file and Medicare rules. Review of the file shows that the services provided was a panel. The 
panel was billed as individual codes. Per Medicare rules, the panel should be billed with one code. Based on 
this information, we decided that Medicare rules for coverage of the genetic testing billed with codes 81408, 
81407, 81170, 81406, 81405, and 81401 have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing billed with codes 81408, 81407, 81170, 81406, 81405, and 81401 for date of 
service June 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87801 and 87500 
for January 3, 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 multiplex tests must be billed with only one testing 
code. 
 
We looked at the file and Medicare rules. The file shows that the panel was not billed with one single testing code. 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 laboratory services billed with codes 
87801 and 87500 for January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit kit for deluxe contour seats (K0108). 
 
You asked the Plan to pre-approve a transit kit. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the requested specialized seating is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a transit kit for deluxe contour seats (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676, E0673, E0667).

You asked the Plan to pay for a pneumatic compression device. You say that this item was medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676, E0673, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.

You asked the Plan to pre-approve a CGM and supplies. You say that you would like to request reconsideration
of the denied authorization. The Plan denied your request. The Plan says that the criteria for approval have not
been met. Maximus overturned the Plan's decision because there was a lack of information. The Plan requested
a reopening and stated that they upheld your request because medical records were not submitted. The Plan is
correct in this case. The Plan has provided proof that they requested records from your physician on multiple
occasions without response. Medicare rules say that for Medicare to consider coverage and payment for any
item or service, the information submitted by the supplier or provider must corroborate the documentation in
the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. Your
provider has not submitted any medical records to confirm you meet Medicare criteria for a CGM and supplies.
Based on this information, we decided that there is insufficient information in the record to determine if
Medicare rules for coverage of a CGM and supplies have been met. Therefore, we decided that the Plan does
not have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) on all 4 quadrants provided 
on August 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were never informed of the additional cost 
and that the same procedure needed to be done again. The Plan denied your request. The Plan says your benefit 
for the requested items or services 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 the Plan paid for the gingival irrigation (D4921) for all 4 quadrants on February 15, 2023; therefore, 
your benefit for the requested items or services was exhausted on the date of service of February 15, 2023. 
Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921) on all 4 quadrants 
provided on August 8, 2023.
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 May 30, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that 99100 should be paid as billed because it is 
supported in the documentation. 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 May 30, 2023.
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 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 is correct in this case. 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.

Based on the medical records provided, the enrollee did not require daily skilled nursing or daily skilled
therapy services at an IRF level of care to return to baseline. Medicare coverage criteria were not 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on January 10, 2023, 
to January 12, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
diagnosis code A41.51 (Sepsis due to Escherichia coli [E. coli]) was accurately reported and billed with the 
appropriate DRG. The Plan denied your request. The Plan says that the medical records did not have sufficient 
documentation to clinically validate the diagnosis of A41.51 (Sepsis due to Escherichia coli [E. coli]). 
 
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 A41.51. 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 physician 
reviewer found that while the patient had a urinary tract infection, the documentation does not support that 
there was a rise in the Sequential Organ Failure Assessment (SOFA) score as required for payer-specific 
coverage. 
 
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 the inpatient hospital services provided on January 10, 2023, to January 12, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered
from February 5, 2023, to February 9, 2023.

You asked the Plan to waive the copayment for these services. You say that you would like an additional $500
taken off your bill. 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 per day for days 1-5 for in-network inpatient hospital care.

Review of the file shows that you received inpatient hospital care from February 5, 2023, to February 9, 2023.

The previous determination stated that the Plan cannot ask you to pay more than $300 per day for days 1-5 for
these services; however, your Plan contract clearly states that there is a $350 copayment per day for days 1-5
for in-network inpatient hospital care. Despite the listed $350 copayment per day, the Plan charged you only a
$300 copayment per day for days 1-5, for a total of $1,500. This item/service falls within the in-network
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 copayment for the inpatient
hospital services rendered from February 5, 2023, to February 9, 2023.