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

We decided that the Plan does not have to pay for the genetic testing (0037U) provided to the enrollee on February 8, 2022.
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan denied your request. The Plan says that genetic testing panels that test for the FANCC gene are non-covered per Medicare Local Coverage Article: Billing and Coding: MolDX: FANCC Genetic Testing (A53628).
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the specimen was collected. We looked at the file and Medicare rules. The file indicates that the DOS of the panel is not the same as the date the specimen was collected. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing (0037U) provided to the enrollee on February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 10, 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 for medical necessity. The Plan requested a reopen and stated that the issue was errors on the claim and not medical necessity. The Plan notes that the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that specimens were collected on January 11, 2022. The specimen was received on February 4, 2022. There is no documentation of molecular pathology testing performed on the date billed of February 10, 2022. The claim was billed with a place of service (POS) code 81 meaning the specimen was taken by a lab independent of an institution or a physician's office. There is no documentation that the sample was taken by the independent lab. The difference in date of collection and date received confirms that the was not collected directly by the laboratory. Also, the claim did not include the required DEX Z-Code or unique test identifier code required by Medicare.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed due to errors with the date of collection reported, the POS code reported and the omission of the required identifier code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 9, 2022.
You asked the Plan to pay for these services. You say that this testing should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met.
Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and stated the issue was not medically necessity but that there were data element errors on the claim itself. The Plan notes the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on November 16, 2021, rather than the billed date of service February 9, 2022. The date of service for a clinical laboratory test or the technical component of physician pathology service must be the date the specimen was collected. The Plan also states the claim did not include the required unique test identifier documentation.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid due to discrepancies with the date of service reported versus the date the specimen was taken as well as the omission of the required test identifier code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided March 31, 2022.
You asked the Plan to pay for the dental services. You say that you need dental care every three months. The Plan denied your request. The Plan says your benefit for the requested item or service 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 your benefit for the requested item or service was exhausted on date of service August 24, 2021.
The records show the Plan paid for periodontal maintenance for you for the dates of service of May 19, 2021, and August 24, 2021. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on June 29, 2021.
You asked the Plan to pay for these services. You say that this testing should be covered 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 noted that the clinical information provided does not support coverage under NCD 90.2, therefore this test is statutory excluded. The Plan also notes the claim was billed with a place of service (POS-81) inconsistent with Medicare rules. An independent laboratory taking a sample in its laboratory shows "81" as place of service. There is no documentation that the specimen was taken by the laboratory directly. The specimen was collected on June 29, 2021, and not received by the laboratory until July 24, 2021, confirming that this sample was not taken by the laboratory directly.
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 could not be paid due to inconsistencies in the dates of service versus the dates the specimens were taken as well as a lack of medical record documentation show the required coverage criteria were met. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on June 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 12, 2022.
You asked the Plan to pay for this testing. You say that this testing should be covered by the Plan. 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 stated that Maximus did not apply the correct billing criteria. The Plan notes the claim was billed with a place of service (POS) code of 81 indicating the specimen was collected by a lab independent of an institution or a physician's office. However, the records show the specimen was collected in the hospital.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed due to an issue with the POS code billed. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 12, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve revascularization, endovascular  
(codes 37228, 37229, 37230 and 37231). 
 
You asked the Plan to pre-approve revascularization, endovascular. You say that revascularization, 
endovascular is medically necessary. The Plan denied your request. The Plan says that revascularization, 
endovascular is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 revascularization, endovascular. Our 
reviewer says that the requested revascularization, endovascular is considered medically reasonable and 
necessary in this case. Our physician reviewer found that the documentation supports the medical necessity and 
possible intervention. The enrollee is describing possible rest pain in the foot and the ankle brachial index 
(ABI) may be artificially elevated due to his diabetes. The enrollee had undergone previous tibial and pedal 
angioplasties and may be having recurrent disease following those treatments and the enrollee may be having 
limb threatening ischemia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization, endovascular have been met. Therefore, we decided that the 
Plan has to pre-approve revascularization, endovascular (codes 37228, 37229, 37230 and 37231).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740). 
 
You asked the Plan to pre-approve the crown. You say that the crown should be covered since it was not long 
before it broke. The Plan denied your request. The Plan says your benefit for the requested item or service 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 6, 2019. Therefore, 
we decided that the Plan does not have to pre-approve a crown (D2740).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from February 1, 2022, to February 20, 2022.
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 the enrollee was under hospice election at the time of service and the claim must be submitted to Original Medicare first. Maximus administratively overturned the Plans denial for a lack of documentation in the case file to confirm the enrollee's hospice election at the time of service. The Plan requested a reopen and provided the required documentation.
The Plan is correct in this case. 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 documentation provided 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 home health services provided to the enrollee from February 1, 2022, to February 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954), 
endodontic therapy (D3320), and additional intraoral periapical x-ray (D0230) provided on September 15, 
2022. 
 
You asked the Plan to pay for the prefabricated post and core, endodontic therapy, and additional intraoral 
periapical x-ray. You say that you were assured by a representative that everything would be covered in full. 
The Plan denied your request. The Plan says the prefabricated post and core and endodontic therapy are not 
covered expenses under your dental plan. The Plan also says your benefits for the additional intraoral periapical 
x-ray have been satisfied and the frequency limitation has been exceeded. 
 
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.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the prefabricated post and core in 
addition to crown (D2954) and endodontic therapy (D3320) are not among those covered under this benefit. 
The contract says intraoral x-rays are limited to 1 procedure code per calendar year. The record shows that you 
received a first intraoral periapical x-ray (D0220) on September 15, 2022, and your intraoral x-rays benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in 
addition to crown (D2954), endodontic therapy (D3320), and additional intraoral periapical x-ray (D0230) 
provided on September 15, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on August 17, 2021.
You asked the Plan to pay for this testing. You say that this claim should be paid by the Plan. 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 notes that testing panels that include the FANCC and BLM genes is statutorily excluded service. The GTC-Hematology Profile panel includes testing for FANCC and BLM. Also, the claim did not include the required DEX Z-Code or unique test identifier code. There also is no documentation of recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer.
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 code. In this case, this claim could not be paid due to the omission of a required testing identifier code and a medical diagnosis to support the services billed. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 23, 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 for medical necessity. The Plan requested a reopen and stated the issue was not medical necessity but the fact that the claim had data element issues. The Plan noted that as well as statutory exclusion, the records show the specimen was collected on January 4, 2022, and not on the billed day of March 23, 2022. The date of service for a clinical laboratory test or the technical complement of physical pathology service must be the date the specimen was collected. The claim also did not include the required unique test identifier code.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim cannot be paid as billed due to inconsistency with the dates of service billed versus the date of specimen collection and the omission of required test identifier codes. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) and a diagnostic 
consultation service (D9310), provided on August 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel like these services were coded 
correctly. The Plan denied your request. The Plan says your benefit for the requested item or service 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for D0330 was exhausted on date of service June 13, 2022. D9310 is not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) and a 
diagnostic consultation service (D9310), provided on August 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for an advanced flex-walk system foot for the enrollee.
You asked the Plan to provide coverage for this request. You say that at the time of the appeal, this advanced foot was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and second review of the records.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a prosthetic leg with an advanced flex-walk system foot. The Maximus Physician Reviewer determined the enrollee shows progression from a K1 ambulation level to a K3 ambulation level. The Plan requested a reopen and argues while the physician state the enrollee is a K3 ambulator, the medical record explicitly documents the need for cane and walker for ambulation which is not consistent with a K3 ambulation level. Review of the medical records show the Plan is correct in this case. The clinical records do not provide sufficient documentation of functional need for the technologic or design feature of an advanced flex-walk system foot. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this request have not been met. Therefore, we decided that the Plan does not have to provide coverage for a prosthetic leg with an advanced flex-walk system foot for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) for teeth numbers 18 and 20, a retainer 
crown (D6751) for teeth numbers 18 and 20, and a pontic-porcelain fused to predominantly base mental 
(D6241) for tooth number 19 provided on September 15, 2022. 
 
You asked the Plan to pay for core buildup (D2950) for teeth numbers 18 and 20, a retainer crown (D6751) for 
teeth numbers 18 and 20, and a pontic-porcelain fused to predominantly base mental (D6241) for tooth number 
19. You say that you phone the Plan for coverage for the entire procedure. You also say you were quoted for 
each step, and you received a letter that coverage was denied. The Plan denied your request. The Plan says 
these services you received are not listed covered benefits under your contract. The Plan also says that you 
signed a treatment plan acknowledging that you would be responsible for the payment for these services. 
 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. 
 
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 core 
buildup (D2950) for teeth numbers 18 and 20, a retainer crown (D6751) for teeth numbers 18 and 20, and a 
pontic-porcelain fused to predominantly base mental (D6241) for tooth number 19 provided on September 15, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive exam (D0150) provided on August 11, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you went in for an issue with your mouth and the 
office never told you that the code was not covered. The Plan denied your request. The Plan says your benefit 
for the comprehensive exam (D0150) 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 27, 2020. Therefore, 
we decided that the Plan does not have to pay for the comprehensive exam (D0150) provided on August 11, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tooth extractions (D7140, D7210) provided September 
13, 2022. 
 
You asked the Plan to pay for the extractions. You say that you disagree with the denial of the extractions. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the tooth extractions (D7140, D7210) provided September 13, 2022.