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

We decided that the Plan does not have to pay for emergency department visit for the evaluation and management of a patient (99284) provided on June 2, 2020.
You asked the Plan to pay for this service. You say that this service should be paid by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan says that this claim denied because the provider did not include the appropriate primary, first-listed or principal diagnosis which is based on the ICD-10-CM Manual. The provider should have billed the toxic agent. The provider did not bill appropriately. The Plan provided the claim images for review. The provider billed, K52.1 for toxic gastroenteritis and colitis, as a "Code first" note and also a "use additional code" note. This was an administrative denial due to a coding error on the claim itself.
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 cannot be paid as billed due to an issue with the primary codes billed. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for emergency department evaluation and management services provided to the enrollee on June 2, 2020 under code (99284).
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for a computed tomography (CT) scan provided on July 11, 2020.
You asked the Plan to pay this claim. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that this claim denied because it was reported without a required anatomical modifier. The Plan states the provider needed to bill the anatomic specific modifiers LT (Left side), RT (Right side), and 50 (Bilateral procedure) to designate the area or part of the body on which the procedure is performed. The Plan submitted claim images to show the required modifier as not billed on the claim. These modifiers are required whenever they are appropriate.
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 and when necessary must report the appropriate modifiers. In this case, the claim cannot be paid as billed due to the omission of a required modifier to identify the specific area of the body the imaging was performed on. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (73700) provided to the enrollee on July 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee.

You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that this claim denied because the provider with an inappropriate place of service code. The Plan provided the claim image that shows the provider billed with place of service code 13 for an Assisted Living Facility. The Plan states this provider is a mobile radiology provider and moves from location to location. The Plan states this claim should have been billed with a place of service code of 15 which is specifically for mobile units. The Plan notes that the NPI website shows this provider is listed at a portable diagnostic imaging supplier.

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 cannot be paid due to an issue with the place of service code reported. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for radiology services provided to the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for evaluation and management services provided to the enrollee on April 9, 2020 and billed under code 99232 for claim A.
You asked the Plan to pay for this service. You say that this claim should be paid by the plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan says claim A denied because the Plan had already made payment for this service under claim B to the same provider group. The Plan provided the claim images for review. The Plan states the NCCI policy manual explains that a distinct services modifier would need to be billed in order to bypass the PTP edit that applied to this claim. Each edit table contains edits which are pairs of HCPCS/CPT codes that in general should not be reported together. Each edit has a column one and column two HCPCS/CPT code. If a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. However, if it is clinically appropriate, the provider should use an NCCI-associated modifier, which was not done in this case.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one 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 service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for evaluation and management services provided to the enrollee on April 9, 2020 and billed under code 99232 claim A.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on October 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for specialist services. You say that you blood pressure was high and you couldn't be seen by an in-network provider for 30 days. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that there are in-network providers available for these services.
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 had network providers available who could have provided 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 October 19, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the portable oxygen concentrator (CPT code E1392).
You asked the Plan to pre-approve the portable oxygen concentrator. You say that your current portable tanks only last 1-2 hours causing severe anxiety that you will run out of oxygen when you are out of the home. The Plan denied your request. The Plan says you are not allowed to have both a stay at home oxygen concentrator and a portable oxygen concentrator. The Plan states your oxygen needs are not high enough to require two concentrators and you do not need a second concentrator due to work or school needs.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. A Simply Go or Simply Go Mini Oxygen Concentrator was requested to be used in addition to your stay at home (stationary) concentrator. The Portable Oxygen Concentrator is being denied, as you have already received your stay at home concentrator. Your needs are not high enough to require two (2) oxygen concentrators. In addition, you do have the option to use the current oxygen tanks when outside the home. The portable concentrator would not last longer than the current tanks. Therefore, we decided that the Plan does not have to pre-approve the portable oxygen concentrator (CPT code E1392).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuropsychological testing.

You asked the Plan to pre-approve the neuropsychological testing services. You say that the enrollee may have
advancing dementia and assessments are time sensitive. The Plan denied your request. The Plan says there is no
clinical evidence to support the medical necessity for neuropsychological testing.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the neuropsychological testing services.
Our reviewer says that the requested neuropsychological testing is not considered medically reasonable and
necessary in this case. Our physician reviewer found the enrollee is not showing a severity of symptoms that
would warrant this type of diagnostic treatment. The criteria for coverage of the requested neuropsychological
testing have not been met, as the documentation is unclear regarding the reasoning for the testing to be
obtained.

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 neuropsychological testing services have not been met. Therefore, we
decided that the Plan does not have to pre-approve neuropsychological testing.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray transportation and set-up (R0070, Q0092) provided on September 16, 2020.
You asked the Plan to pay for portable x-ray transportation and set-up. You say that this was billed correctly. The Plan denied your request. The Plan says this is not separately payable from the SNF stay.
The Plan must follow Medicare rules. Medicare rules say that when a skilled nursing facility (SNF) resident receives a portable x-ray service during the course of a Medicare-covered stay in the SNF, only the service's professional component is a separately billable physician service under Part B. By contrast, the technical component representing the procedure itself, including any associated transportation and setup costs, would be subject to consolidated billing and must be included on the SNF's Part A bill. We looked at the file and Medicare rules. The services at issue are technical components and must be included on the facility's Part A bill. These services are not separately payable. Based on this information, we decided that Medicare rules for coverage of portable x-ray transportation and set-up have not been met. Therefore, we decided that the Plan does not have to pay for portable x-ray transportation and set-up (R0070, Q0092) provided on September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210).

You asked the Plan to pay for the dental services. You say that on page 4-70 of the 2020 plan materials it says
that D7210 is covered, and the plan pays 50%. The Plan denied your request. The Plan says surgical extraction
is not listed as a covered service. The Plan says that any services not listed are not covered. The Plan also says
that you were not enrolled in the optional supplemental dental rider on this date of service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the surgical extraction is not among
those covered under this benefit. The record shows that you were not enrolled in the optional supplemental
dental benefit in which this service is covered under. Therefore, we decided that the Plan does not have to pay
for the surgical extraction (D7210).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing.

You asked the Plan to pay for the COVID-19 testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and ordering physician.

The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the COVID-19 testing have not been met. Specifically, there is no evidence that the ordering physician is treating the member. Of note, the ordering physician is located in Illinois while the member and laboratory are located in Texas. Therefore, we decided that the Plan does not have to pay for the COVID-19 testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the mechanical traction therapy services received from September 30, 2020 to October 9, 2020.
You asked the Plan to pay for the mechanical traction therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. In addition, the services received do not fall within the fitness benefit, naturopathic services, or acupuncture. These services do not fall within the "wellness wallet" benefit category of your Evidence of Coverage. Therefore, we decided that the Plan does not have to pay for the mechanical traction therapy services received from September 30, 2020 to October 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from January 26, 2021,
forward.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in
denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary.
Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable
skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do
not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at
this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules
for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve
continuation of SNF care from January 26, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 2, 2020.
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 services rendered by non-participating providers require 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 had network providers available who could have provided 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 laboratory services provided to the enrollee on November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services provided to the enrollee on September 9, 2020.
You asked the Plan to pay for the services. You say that you never needed a referral with this insurance before. The Plan denied your request. The Plan says both the rendering and referring provider is not participating.
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 had network providers available who could have provided 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 ophthalmology services provided to the enrollee on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (CPT 72082, CPT 96372, CPT J3420) provided to the enrollee on August 5, 2020.
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 72082: Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine 2 or 3 views HCPCS J3420: Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg CPT 96372: Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found CPT 72080 is not supported by the documentation submitted. Radiology reports include radiology services performed on the right arm, lumbar spine and left hip. Therefore CPT 72080 cannot be confirmed as performed. HCPCS J3420 and CPT 96372 is not supported by the documentation submitted. Documentation did not include B-12 injection. This medication is documented under current medications in office note, however, documentation does not confirm inject was given. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (CPT 72082, CPT 96372, CPT J3420) provided to the enrollee on August 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care following an elective right total
hip arthroplasty.
You asked the Plan to pre-approve acute inpatient hospital care. You say that you are having a major surgery
and will need assistance immediately after. The Plan denied your request. The Plan says the planned procedure
listed under CPT code 27130 is not listed on the CMS Inpatient Only List.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of acute inpatient hospital care have not been met. The planned procedure listed under CPT code
27130 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory
procedure. There is no documentation provided to support the expectation that you will require a greater than
two midnight stay. If you experience any peri- or post-operative complications, reconsideration for inpatient
level of care can be performed on concurrent review with updated clinical information. Therefore, we decided
that the Plan does not have to pre-approve inpatient hospital care following an elective right total hip
arthroplasty.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for electrocardiogram (93010) provided to the enrollee and billed under claim A.

You asked the Plan to pay for this service. You say that this service should be paid by the Plan. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan states that this claim denied because the Plan previously paid for this service under claim B. The Plan states they previously paid for both the professional and interpretation of this service. The Plan states the NPI Registry shows both billing providers practice the same specialty and both providers belong to the same provider group. Therefore, the second claim, or claim A was denied.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one 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 service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for electrocardiogram (93010) provided to the enrollee and billed under claim A.