Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on March 31, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service March 31, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant360 testing provided on March 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the other tissue grafts services coded 20926 provided on 
December 18, 2019. 
 
You asked the Plan to pay for the other tissue grafts services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 20926 is not supported in the medical record. Specifically, the operative report did not 
include documentation of other) paratenon, fat, dermis) tissue grafts. Based on this information, we decided 
that Medicare rules for coverage of the other tissue grafts services have not been met. Therefore, we decided 
that the Plan does not have to pay for the other tissue grafts services coded 20926 provided on December 18, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 20, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that your doctors are on-call. You say that it is the 
facility's responsibility to obtained prior authorization. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home health services provided on February 20, 
2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from January 21, 2020 to 
January 24, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that the intensity of service provided was 
appropriate, medically necessary, and reasonable. The Plan denied your request. The Plan says the denial of 
payment for this inpatient stay is correct, because this post-stabilization care was not approved by the Plan.  
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient hospital care. Our reviewer says 
that this inpatient hospital stay does not meet the Medicare criteria for coverage. Our physician reviewer found 
the enrollee was hemodynamically stable and appropriate for ambulance transportation with monitoring to an 
in-network facility after the emergency room evaluation on January 21, 2020. There was no documentation 
provided requiring post-stabilization care services at the out-of-network facility. The post-stabilization care 
services from January 21, 2020 to January 24, 2020 were not medically necessary or reasonable. The treating 
physician did not document that the enrollee was not stable for transfer on these dates of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient hospital care provided from January 21, 2020 to January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac device monitoring services provided on May 13, 
2020. 
 
You asked the Plan to pay for Interrogation device evaluation(s) (remote), up to 90 days (93294, 93296). You 
say that the Plan should pay this claim. The Plan denied your request. The Plan says the services were provided 
more than once per 90 days. 
 
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 93294, 93296 is Interrogation device evaluation(s) 
(remote), up to 90 days; single, dual, or multiple lead pacemaker system, or leadless pacemaker system with 
interim analysis, review(s) and report(s) by a physician or other qualified health care professional. 
 
The last paid service was February 14, 2020 and 90 days from then is May 14, 2020. These services can only 
be reported once per 90 days. Based on this information, we decided that Medicare rules for coverage of 
Interrogation device evaluation(s) (remote), up to 90 days (93294, 93296) have not been met. Therefore, we 
decided that the Plan does not have to pay for cardiac device monitoring services provided on May 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an X-ray provided on December 2, 2019 
 
You asked the Plan to waive the copayment for an X-ray. You say that you were told that your x-rays would be 
included in the charge for a previous visit. The Plan denied your request. The Plan says the copayment you are 
being charged is correct. 
 
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 $10 
copayment for each Medicare-covered standard X-ray service.  
 
You have been asked to pay a $10 copayment for an X-ray. An X-ray 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. Therefore, we decided that the Plan does not have to waive the copayment 
for an X-ray provided on December 2, 2019
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management provided on October 
3, 2019. 
 
You asked the Plan to pay for the hospital discharge day management. You say that modifier GV was used and 
therefore should be paid. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management provided on October 
3, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular genetic testing provided on February 2, 2020. 
 
You asked the Plan to pay for the molecular genetic testing. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the molecular genetic testing 
provided on February 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living care provided on February 17, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for assisted living care. You say that it is the facility's responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the facility, 
member, or provider. 
 
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 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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for assisted living care provided on February 17, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999) provided on May 27, 
2020. 
 
You asked the Plan to pay for the preventive procedure. You say that you have not been able to receive dental 
care for a year. You also say that you were given approval by your oncologist to receive dental care, and you 
would like this to be completed quickly in order to maintain your overall health. The Plan denied your request. 
The Plan says this service is not a covered benefit under your dental plan. 
 
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 the 
preventive procedure (D1999) provided on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interrogation device evaluation(s) coded 93297 provided 
on March 17, 2020. 
 
You asked the Plan to pay for the interrogation device evaluation(s). You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 93297 
for the interrogation device evaluation(s) has a bundled relationship with code 93296 and cannot be paid as 
billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for the interrogation device 
evaluation(s) coded 93297 provided on March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing provided on April 18, 2020.

You asked the Plan to pay for the testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 the testing  is not supported in the medical record. Specifically, this service should be coded with code 81479. In addition, the appropriate code should be entered adjacent to the code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing provided on April 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on February 17, 2020 by an out of network provider.

You asked the Plan to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336). You say that your physician provided the service and deserves to be reimbursed. The Plan denied your request. The Plan says you did not request prior authorization.

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 requested 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. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the physician services provided on February 17, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on June 18, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that you were told that prior authorization was not 
required. The Plan denied your request. The Plan says prior authorization is required for out-of-network 
providers. The Plan says that prior authorization was not obtained. 
 
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 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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for specialist services provided on June 18, 2020 by 
an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a tenotomy provided on July 9, 2019. 
 
You asked the Plan to waive the coinsurance for a tenotomy. You say that the experience was a disaster and 
nightmare and you found a different doctor. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 10% 
coinsurance for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You received a tenotomy on July 9, 2019. The allowed amount is $2,290.11 and 10% of that is $229.04. 
 
You have been asked to pay the total coinsurance amount of $229.04 for a tenotomy. A tenotomy falls within 
the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 coinsurance for a tenotomy provided on 
July 9, 2019.  
 
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit 
MAXIMUS to make a decision on this type of complaint.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment (A0998) provided on 
February 28, 2020. 
 
You asked the Plan to pay for the ambulance response and treatment. You say that you would like 
reconsideration because the services rendered were medically necessary and provided in good faith. The Plan 
denied your request. The Plan says the procedure code billed is not a covered service under Medicare. 
 
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 A0998 is ambulance response and treatment, no 
transport.  
 
We find that CPT code A0998 is not supported in the record. Specifically, per Medicare, CPT code A0998 has 
a status indicator of I. This means that CPT code A0998 is not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of the ambulance response and treatment have not 
been met. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment 
(A0998) provided on February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on March 3, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services provided on March 3, 2020 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition supplies rendered from March 12, 
2020 to March 18, 2020. 
 
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 there is no detailed written order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any DMEPOS item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 parenteral nutrition supplies rendered from March 12, 2020 
to March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living care provided on May 28, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for assisted living care. You say that it is the facility's responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the 
provider, facility or member. 
 
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 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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for assisted living care provided on May 28, 2019 by 
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the immediate upper and lower denture (D5130 and 
D5140) provided on February 5, 2020. 
 
You asked the Plan to pay more for the immediate upper and lower denture (D5130 and D5140). You say that 
the dentures did not fit so you couldn't wear them. You say that you should get a full credit towards your 
permanent dentures. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 Plan is only obligated to pay 50% 
of the allowed amount for the dentures. Therefore, we decided that the Plan does not have to pay more for the 
immediate upper and lower denture (D5130 and D5140) provided on February 5, 2020.