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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 16, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and each 
additional intraoral periapical x-ray (D0230) provided on April 26, 2022. 
 
You asked the Plan to pay for the first intraoral periapical x-ray (D0220) and each additional intraoral 
periapical x-ray (D0230). You say that you are appealing this denial. You say you would like to be provided 
with any records and documents used to make the decision. The Plan denied your request. The Plan says the 
services are not covered 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. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the first intraoral periapical x-ray 
(D0220) and each additional intraoral periapical x-ray (D0230) services are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) 
and each additional intraoral periapical x-ray (D0230) provided on April 26, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 2, 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 for a lack of information in the case file. The Plan requested a reopen and provided additional information. The Pan 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 February 7, 2022 and received on February 23, 2022. There is no documentation of molecular pathology testing performed on the date billed of March 2, 2022. 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 records show the specimen was taken at the hospital. There is no documentation that the sample was taken in the laboratory. The difference in date of collection and date received confirms that the was not collected directly by the laboratory. In addition, the claim did not include the required DEX Z-Code or 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. Providers must report services with the appropriate codes. In this case, this claim could not paid due to inconsistencies with the dates of service versus the dates the specimen was collected and the omission of the required test identifier. 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 March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the StrataNGS testing (81479) provided to the enrollee on July 24, 2021.
You asked the Plan to pay for the testing. You say that this test was approved by the MolDX program and is medically necessary for this enrollee. The Plan denied your request. The Plan says that the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services.
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 test is not the same as the date the specimen was collected. 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 StrataNGS testing (81479) provided to the enrollee on July 24, 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 17, 2022.
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 for medical necessity. The Plan requested a reopen and noted that this was not a medical necessity issue but an administrative billing issue. 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 a specimen was collected on February 13, 2022. There is no documentation of molecular pathology testing performed on the date billed of March 17, 2022. The claim also did not include the required DEX Z-Code our unique test identifier code. Medicare rules state no payment is made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period. 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 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 billed due to issues with the dates of service reported and the omission of the required test identifier codes. 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 March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 14, 2022.
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 stated that per Box 32 of the claim form show the services were rendered. The provider did not include any laboratory results documenting that the service billed was performed on the date of service reported.
Without the laboratory report and associated information, the Plan does not have the information necessary to verify the services billed were rendered as billed. The rules state the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
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, the records provided do not 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 February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for to pay for genetic testing provided to the enrollee on July 21, 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 coverage criteria were not met. Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and provided several reasons for non-payment of this claim. The Plan states that the claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. However, the sample was collected in the provider's office/outpatient facility and shipped to the laboratory. There is no documentation that the specimen was 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. In this case, this claim cannot be paid as billed due to issues with the POS code and the documentation on where the specimen was taken. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for to pay for genetic testing provided to the enrollee on July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 15, 2022.
You asked the Plan to pay for this service. 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 not medical necessity but the omission of required data elements on the claim. The Plan notes the records submitted show that a specimen was collected on December 21, 2021. The specimen was received on February 6, 2022. There is no documentation of molecular pathology testing performed on the date billed of February 15, 2022. The claim was also 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. There is no documentation that the sample was taken in the billing or independent laboratory. 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.
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 as billed due to inconsistencies with the dates billed and the omission of a required identifying code. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional routine transportation trips for the enrollee.
You asked the Plan to pre-approve ten (10) additional routine transportation trips. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that the enrollee is not eligible for an additional ten routine transportation trips.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of forty-eight (48) trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional routine transportation trips for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 11, 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 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 noted that while the test was billed on the date the report was signed, there is no documentation that the specimen was collected from an outpatient hospital encounter. The claim form lists the POS code as 81, which would infer the specimen was taken by the independent lab. The date of service for the clinical lab test or technical component of physician pathology services must be the date the specimen was collected. The exception to the general rule does not apply as the provider indicates the POS code was 81 or independent lab collection. In addition, the records submitted show the specimens were collected on December 23, 2021. There is no documentation of testing performed on February 11, 2022. Therefore, Medicare coverage criteria are not met.
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 errors with the dates of service reported and the POS code. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for genetic testing provided to the enrollee on February 7, 2022.
You asked the Plan to pay for these services. 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 for medical necessity. The Plan requested a reopen and stated the issue was not medical necessity, but billing errors reported on the claim. 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 October 27, 2020. The specimen was received on January 28, 2022. There is no documentation of molecular pathology testing performed on the date billed of February 7, 2022. 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. The sample was collected by the hospital and sent to the provider. There is no documentation that the sample was taken in the laboratory. The difference in date of collection and date received confirms that the was not collected directly by the laboratory. The claim also does not include the required DEX Z-Code or 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. Providers must report services with the appropriate code. In this case this claim could not be paid due to inconsistencies with the dates of service billing 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 to pay for genetic testing provided to the enrollee on February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 15, 2022.
You asked the Plan to pay for these services. 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 for insufficient information in the case file. The Plan requested a reopen and provided additional information. 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 28, 2022. The specimen was received on February 9, 2022. There is no documentation of molecular pathology testing performed on the date billed of February 15, 2022. The claim was also 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. The sample was collected by a hospital. There is no documentation that the sample was taken in the billing laboratory. The difference in date of collection and date received confirms that the specimen was not collected directly by the laboratory. In addition, the claim did not include the 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. Providers must report services with the appropriate codes. In this case, this claim could not be paid due to inconsistencies with the dates billed and 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 15, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 16, 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 lacked Medicare required data elements for payment. The Plan noted the records show the specimens were collected on June 9, 2021, November 3, 2021, and February 6, 2022. There is no documentation of molecular pathology testing performed on the date billed of February 16, 2022. 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. The test requisition noted the sample was to be collected by mobile phlebotomy. There is no documentation that the sample was taken in the laboratory. This is confirmed by the documentation that the specimen was collected on February 6, 2022, and not received until February 8, 2022. Finally, the claim did not include the required DEX Z-Code or unique test identifier 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. Providers must report services with the appropriate codes. In this case, this claim could not be paid as billed due to discrepancies with the dates of service reported and the omission of the required unique 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 16, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 4, 2022
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 upheld the Plans denial for medical necessity. The Plan requested a reopen and stated the issue was both statutory exclusion and issues with data elements on the claim that created errors. The Plan agrees with the diagnosis of a a solid tumor. However, this is an administrative determination for non-coverage and is not based on clinical criteria for medical necessity. The Plan states the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on December 13, 2021, rather than the billed date of service January 4, 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 claim also 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. Providers must report services with the appropriate codes. In this case, this claim could not be paid due to inconsistencies with the dates of service versus the date of specimen collection and the omission of the unique test identifier required by Medicare. The 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 January 4, 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 8, 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 is not medical necessity but the billing errors on the claim. 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 24, 2022. The specimen was received on February 1, 2022. There is no documentation of molecular pathology testing performed on the date billed of February 7, 2022. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. However, the records show the specimen was collected by the imaging facility. There is no documentation that the sample was taken in the laboratory. The difference in date of collection and date received confirms that the was not collected directly by the laboratory. Medicare rules state 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. POS code 81 is only used to describe samples taken directly by the independent laboratory. In addition, the DEX-Z code or unique test identifier code required by Medicare was not submitted with the claim.
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 with the dates of service versus the dates of specimen collection and the omission of a 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 8, 2022.