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

We decided that the Plan does not have to pay for the lab services (81479) provided to the enrollee on April 13, 2022.
You asked the Plan to pay for the lab services. You say that you want the Plan to pay for the service at issue. The Plan denied your request. The Plan says that the specimen was collected during an outpatient encounter.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. 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 cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the lab services (81479) provided to the enrollee on April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service August 13, 
2022. 
 
You asked the Plan to pay for procedure code(s) 85060. You say that these services were medically necessary 
and billed correctly. The Plan denied your request. The Plan says this code is included in the facility payment 
and is not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 85060. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 85060. Based on this information, 
we decided that Medicare rules for coverage of procedure code 85060 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service August 13, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neck/spine x-ray (CPT 72040-26), x-ray of jaw 
(CPT 70100-26), swallowing function x-ray (CPT 74230-26), upper gastrointestinal tract x-ray  
(CPT 74240-26), radiologic examination, chest; single view (CPT 71045), and radiologic examination, teeth; 
partial examination, less than full mouth (CPT 70310) provided on August 30, 2022. 
 
You asked the Plan to pay for a neck/spine x-ray (CPT 72040-26), x-ray of jaw (CPT 70100-26), swallowing 
function x-ray (CPT 74230-26), upper gastrointestinal tract x-ray (CPT 74240-26), radiologic examination, 
chest; single view (CPT 71045), and radiologic examination, teeth; partial examination, less than full mouth 
(CPT 70310). You say that the services were medically necessary. The Plan denied your request. The Plan says 
the services do not meet the Medicare coverage criteria. 
 
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 a neck/spine x-ray (CPT 72040-26), x-ray of jaw (CPT 70100-26), swallowing function x-ray 
(CPT 74230-26), upper gastrointestinal tract x-ray (CPT 74240-26), radiologic examination, chest; single view 
(CPT 71045), and radiologic examination, teeth; partial examination, less than full mouth (CPT 70310) have 
not been met. Therefore, we decided that the Plan does not have to pay for a neck/spine x-ray (CPT 72040-26), 
x-ray of jaw (CPT 70100-26), swallowing function x-ray (CPT 74230-26), upper gastrointestinal tract x-ray 
(CPT 74240-26), radiologic examination, chest; single view (CPT 71045), and radiologic examination, teeth; 
partial examination, less than full mouth (CPT 70310) provided on August 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 15, 2022, to 
July 14, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date.  Subsequent claims must report this new date as the admission date in order for the claim to be matched to the 
correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 15, 2022, to July 
14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 14, 2022, to 
April 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the process change from 
accepting Requests for Anticipated Payments (RAPs) to requiring NOAs was not communicated which led to 
these errors. You feel that the claims should be paid as this requirement was not known at the time the claims 
were submitted. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 14, 2022, to April 
12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 8, 
2022, to August 19, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says 
this stay is denied, and the claim can be resubmitted under Part B. 
 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 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found based on the workup being essentially unremarkable without evidence of 
encephalopathy and the main goal with admission was to arrange for placement, it was not expected that the 
enrollee would require hospital services that would be likely to cross 2 midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from August 8, 2022, to August 19, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the services you received on March 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the maximum 
amount covered by your plan for this service has been paid. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the services by a contract provider. The file does not show that the Plan provided notice 
that the services would not be covered. Under Medicare rules, this means the services is considered approved 
by the Plan. Additionally, the Plan has not provided documentation showing that the maximum allowable for 
code G0103 has been met. The documentation submitted does not show that this code was previously paid by 
the Plan. Therefore, we decided that the Plan has to pay for the services you received on March 24, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded with procedure codes 87481, 
87491, 87496, 87500, 87529, 87532, 87563, 87591, 87640, 87641, 87651, 87653, 87661 and 87798 provided 
July 5, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you do not personally see the patients and you 
are dependent on receiving patient information from the ordering provider. The Plan denied your request. The 
Plan says there is not enough information to consider this charge. 
 
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 pay for the genetic testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee underwent polymerase chain reaction (PCR) urine testing. 
Polymerase chain reaction may be useful when culture is difficult due to the low numbers of the organisms, for 
fastidious or lengthy culture requirements, or when there is difficulty in collecting an appropriate sample.  
Quantification of viral load via PCR may be useful when the viral load can be used as a prognostic indicator, or 
when necessary, follow the patient's response to therapy. Urine PCR testing is not the standard of care. The 
review has determined that the items/services at issue in this case are not medically reasonable or necessary. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the genetic testing coded with procedure codes 87481, 87491, 87496, 87500, 87529, 87532, 
87563, 87591, 87640, 87641, 87651, 87653, 87661 and 87798 provided July 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 85651 and 86140 billed for date of service 
October 4, 2022. 
 
You asked the Plan to pay for procedure codes 85651 and 86140. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 85651 and 86140 is 1. The MAI value for this code is 2. You billed 2 
units of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 85651 and 86140 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 85651 and 86140 billed for date of service October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the GYN office visit provided on November 29, 2021.
You asked the Plan to pay for the GYN office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says that your Plan does not cover more than 1 routine GYN visit every 24 months and you have reached the limit for this service.
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 they cover Pap tests and pelvic exams once every 24 months. The record shows your benefit for the requested item or service was exhausted on date of service November 30, 2020. Therefore, we decided that the Plan does not have to pay for the GYN office visit provided on November 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF care was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. At the time of the appeal, your physical abilities did not appear to allow you to participate in an intensive rehabilitation therapy program at least three hours per day at least five days per week.
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 2, 2021, billed 
with codes 81401, 81286, 81407, 81439, 81405 and 81406. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 2, 2021, billed with codes 81401, 81286, 81407, 81439, 81405 and 81406.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing (81455) provided to the enrollee on April 15, 2022.
You asked the Plan to pay for the genetic testing. You say that these services were necessary and are supported as billed. The Plan denied your request. The Plan says that the specimen was collected during a hospital outpatient encounter.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, 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. Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing (81455) provided to the enrollee on April 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 7, 2022, to 
March 16, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support diagnosis code J96.91. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.91, defined as 
respiratory failure, unspecified with hypoxia. We asked our physician reviewer to carefully review the case file 
and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
inpatient hospital services at the DRG originally billed. Our reviewer says that J96.91 is not supported by the 
documentation. Our physician reviewer found the enrollee is a female who was treated in the hospital with 
osteoarthritis and underwent left total knee arthroplasty without complication. However, hypoxia due to 
atelectasis or possible chronic obstructive pulmonary disease (COPD) was noted and treated with low dose 
oxygen support via nasal cannula. The patient did not require high flow oxygen, bilevel positive airway 
pressure (BiPAP), or full mechanical ventilation which would be required to report respiratory failure. As such, 
this diagnosis is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 7, 2022, to March 16, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88360 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for procedure code 88360. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 88360 is bundled into payment for code 88321. 
 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 88360 
is a column II code to column I code 88321. 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 88360 billed for date of service September 13, 
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met. Maximus overturned the Plans denial stating IRF care would be necessary. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. The rules are clear that you must meet specific criteria prior to admission for IRF care to be covered.
The medical records do not clearly show that at the time of the appeal the enrollee required treatment by a rehabilitation physician three days per week nor did the enrollee require three hours of therapy five days per week. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial. The Plan denied your 
request. The Plan says the request is not medically necessary. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.