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

We decided that the Plan does not have to pay for the subsequent hospital inpatient or observation care services (99232) provided to the enrollee on August 2, 2022.
You asked the Plan to pay for these services. You say that the enrollee was seen by providers with different specialties on this date. The Plan denied your request. The Plan says that the payment for code 99232 is included in the payment for code 99239 billed for the same date of service.
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. We looked at the file and Medicare rules. The file indicates the Plan has already paid for one evaluation and management service (99239) on this date to another provider in the same group practice with the same specialty. 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 subsequent hospital inpatient or observation care services (99232) provided to the enrollee on August 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by an 
in-network provider from December 15, 2022, to December 19, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not think you 
should be responsible for this copayment. 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 $220 
copayment per day, days 1-5, for in-network inpatient hospital care. 
 
 
 You have been asked to pay a $880 copayment for the inpatient hospital stay ($220 x 4 days = $880). This 
item/service falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the inpatient hospital stay provided by an in-network provider from December 15, 2022, to 
December 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

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

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

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic substrate (D2740) and core 
buildup, including any pins when required (D2950) for Tooth #5 and 13. 
 
You asked the Plan to pre-approve dental services. You say that you would like requested services approved to 
help save your teeth. The Plan denied your request. The Plan says these services are not covered under your 
Plan. 
 
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. Crown - porcelain/ceramic 
substrate (D2740) and core buildup, including any pins when required (D2950) are not covered under the 
Plans dental benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2740 and D2950 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
crown - porcelain/ceramic substrate (D2740) and core buildup, including any pins when required (D2950) for 
Tooth #5 and 13.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the double lung transplant to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the double lung transplant. You say that you would like to see an out-of-
network provider. The Plan denied your request. The Plan says you must get your care from network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the double lung transplant to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided on October 
20, 2022. 
 
You asked the Plan to pay for evaluation and management services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for evaluation and 
management services provided on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that there are no in network physician to provide the 
necessary services. The Plan denied your request. The Plan says this is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0666, 97760 and E0673)
billed to the enrollee from June 24, 2022, to July 13, 2022.
You asked the Plan to pay for this device. You say that this device was medically necessary for the enrollee.
The Plan denied your request. The Plan says the Medicare coverage criteria were not met as this device is not
covered for prevention of deep vein thrombosis. Maximus overturned the Plans denial for a lack of required
information in the case file. The Plan requested a reopen and submitted the required information.
The Plan is correct in this case The Plan follows Medicare rules. The rules state that 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 (E0666, 97760 and E0673) billed to the enrollee from June 24, 2022, to July 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
24, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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 code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 70450 billed for date of service December 24, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for out of network providers.
You asked the Plan to provide coverage for out of network providers. You say that you prefer to see the requested out of network provider. The Plan denied your request. The Plan says this service can be provided in network. Maximus overturned the Plans denial because the 2023 contract was not submitted with the case file. The Plan requested a reopen and submitted the correct Plan contract.
The Plan is correct in this case. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to provide coverage for out of network providers.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration 
for the denial of an IRF admission. The Plan denied your request. The Plan says the IRF services you are 
requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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 pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says admission to an IRF is not medically necessary 
at this time. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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 pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgery services provided to the enrollee on March 17, 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 were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that code 47379 was denied as incidental to the primary procedure code 43775. Both procedures were performed through the same laparoscopic trocar incisions. The sleeve gastrectomy was the more complex and extensive of the two procedures, whereas the liver biopsy was incidental, and the pathologic evaluation was completed post-operatively.
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 was billed in error due to the billed code's relationship to the primary procedure code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for surgery services provided to the enrollee on March 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from October 5, 2021, to October 30, 2021.
You asked the Plan to pay for all services billed. 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 for a lack of medical records in the file. The Plan requested a reopen and stated that this was not a medical issue but a billing issue regarding errors with the submitted claim. The Plan states that initially this claim denied on May 31, 2022, due to the facility not providing a detailed line by line itemized bill for review. Without the itemized bill the Plan was unable to validate any of the charges billed by the provider. Once the itemized bill was received on October 24, 2022, the Plan determined several items and services initially denied due to not having an itemized bill have now been identified as routine items and services and were paid. The Plan denied the routine items and services billed with denial code "G", ($57,972.84). These items and services were determined to be inclusive to either room and board or the procedure and not separately reimbursed. The Plan provided an Itemized Bill Summary of denied and approved charges.
The Plan states after review of both the itemized bill and the medical records received, the remaining denied charges totaling $636,641.75 initially denied for a missing itemized bill and/or missing medical records are now approved. The Facility has recently provided the itemized bill allowing us to identify and validate the charges utilizing both the itemized bill and medical records provided.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must submit itemized bills and also submit codes that are payable based on the Medicare billing guidelines. The Plan provided documentation to show those services that were billed appropriately were paid. Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee from October 5, 2021, to October 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99211 billed for date of service September 29, 2021.
You asked the Plan to pay for procedure code 99211. You say that you would like this to be paid for by the Plan. The Plan denied your request. The Plan says payment for code 99211 is bundled into payment for code G0008.
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 code 99211 is a column II code to column I code G0008 with a modifier indicator of 0. The column II code is therefore not payable. 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 code 99211 billed for date of service September 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Electrophysiologic Evaluation (93656) 
and additional intracardiac catheter ablation (93657). 
 
You asked the Plan to pay for the longstanding persistent atrial fibrillation. You say that the service should be 
covered. The Plan denied your request. The Plan says there is no prior authorization. 
 
Medicare rules say that plans may require enrollees to obtain authorization before receiving services. 
 
There was no prior authorization for this service. Therefore, we decided that the Plan does not have to pay for 
the Comprehensive Electrophysiologic Evaluation (93656) and additional intracardiac catheter ablation 
(93657).