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

We decided that the Plan does not have to pay for lab services provided to the enrollee on June 7, 2022 and billed under codes 80307 and 83789.
You asked the Plan to pay for any of 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 partially overturned the Plans denial and instructed payment of code 80307. The Plan requested a reopen and provided additional claim information. The Plan noted that per NCCI Chapter 10, Section E for Drug Testing, beginning January 1, 2017, presumptive drug testing may be reported with CPT codes 80305-80307. These codes differ based on the level of complexity of the testing methodology. Only one code from this code range may be reported per date of service. Beginning January 1, 2016, definitive drug testing may be reported with codes G0480-G0483. These codes differ based on the number of drug classes including metabolites tested. On January 1, 2017, code 00659 defining a different type of definitive drug testing was added. Only one code from this group of codes may be reported per date of service. Providers performing validity testing on urine specimens used for drug testing shall not separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not separately billed. The claim for date of service June 07, 2022, was billed with a presumptive drug testing code 80305.
Per the Medicare guidelines, only one code from range 80305-80307 may be reported per date of service.
Therefore, the denial of code 80307 was appropriate as it is also a presumptive drug testing code within the code range 80305-80307.
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. Regarding code 83789, Medicare rules for coverage of validity testing have not been met. The testing described by the billed code is considered specimen validity testing which is not separately payable. Regarding code 80307, this code was reported in error based on the Medicare billing guidelines. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on June 7, 2022, and billed under codes 80307 and 83789.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 20, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 20, 2023, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from March 
20, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of March 20, 2023, forward. Our physician reviewer found the 
enrollee did not require inpatient mental health treatment beyond March 20, 2023, as she was not a danger to 
herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollee's condition or for the 
purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from March 20, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 20, 
2023, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $10 copayments charged for physician services provided
June 30, 2022, to July 1, 2022.
You asked the Plan to waive these copayments. You say that you only saw the doctor for five minutes and
should not be charged. The Plan denied your request. The Plan says this cost sharing was charged correctly.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct coverage criteria.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay $10 copayment for
physician services. These copayments were charged based on the claims submitted by your provider and the
Plan contract agreement. This cost sharing is a contractual obligation you agreed to pay when you enrolled in
the Plan. Therefore, we decided that the Plan does not have to waive the $10 copayments charged for physician
services provided June 30, 2022, to July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on April 9, 2022,
because of a specimen submitted by a facility.
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 this specimen was submitted by the facility. Payment for this service would be included
in the claim submitted by the provider. 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. Medicare rules say that providers must
report services correctly. Medicare does not pay any provider or supplier other than the facility or hospital for
services furnished to the enrollee.
The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under
arrangements made with outside providers. This specimen was collected by the facility and sent to you by the
facility. Payment for this service would have been included under the facility claim. Payment to you for this
service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay
for lab services provided to the enrollee on April 9, 2022, because of a specimen submitted by a facility.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve SNF care. You say that at the time of the appeal. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus administratively overturned the Plans denial because the case file did not include medical records for review. The Plan requested a reopen and submitted the required medical records.
The Plan is correct in this case. 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. Based on the medical records provided, at the time of the appeal, the enrollee did not require daily skilled nursing or daily skilled therapy services at an inpatient level of care in a SNF facility. Specifically, the medical records show the recommendation after hospital discharge was home health care as the enrollee was at baseline. Medicare rules for coverage of SNF care were not met at the time of the appeal. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for therapeutic glucose continuous monitor system
(K0554) and supply allowance used with a therapeutic continuous glucose monitor (CGM) device (K0553).
You asked the Plan to provide coverage for this equipment. You say that this equipment is medically necessary.
The Plan denied your request. The Plan says all the required Medicare coverage criteria are 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. Medicare rules say that therapeutic
CGMs are covered when all of the required criteria are met. Based on the medical records provided, you do not
meet all of the criteria required by Medicare. In specific the medical records do not show you require frequent
adjustments to the insulin regimen based on blood sugar testing results.
Based on this information, Medicare rules for coverage of this equipment have not been met. Therefore, we
decided that the Plan does not have to provide coverage for therapeutic glucose continuous monitor system
(K0554) and supply allowance used with a therapeutic continuous glucose monitor (CGM) device (K0553).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on April 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims require distinct 5-position, 
alphanumeric home health HIPPS codes 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the correct HIPPS 
code. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the home health services rendered on April 
29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on July 11, 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 is missing required information. 
 
The Plan follows Medicare rules. The rules say that for home health claims must be submitted with all required 
information.  
 
In addition to reporting a visit line using the G codes, home health agencies must report an additional line item 
with the same revenue code and date of service, reporting one of the three Q codes (Q5001, Q5002, and 
Q5009), one unit and a nominal covered charge (e.g., a penny). Review of the file shows that the required Q 
code was not billed on the claim for this date of service. 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 on July 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on 1/27/2022 billed with code 
77065-26-LT. 
 
You asked the Plan to pay for imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim line is a duplicate of a previously paid 
claim line and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 3, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for imaging services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for imaging services provided on 1/27/2022 
billed with code 77065-26-LT.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on 
September 27, 2022. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says the records do not 
support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The records 
provided do not contain an itemized packing slip or delivery ticket showing that the specific items in question were delivered. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment 
(DME) provided on September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a GeneSight Psychotropic Assay (81479) provided on 
June 9, 2022. 
 
You asked the Plan to pre-approve genetic testing. You say that according to the Medicare LCD, the requested 
testing should be eligible and medically necessary. The Plan denied your request. The Plan says the requested 
service is not approved in compliance with the health plan's authorization procedures. The service required a 
prior authorization. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The LCD states for the requested service to be covered, the 
enrollees medical record must clearly reflect that the clinician has made an initial personalized decision for 
the enrollee based on the enrollees diagnosis, the other medical conditions, other medications the enrollee is 
taking, professional judgement, clinical science, and basic science pertinent to the drug, the enrollees past 
medical history and when pertinent family history and the enrollees preferences and values. The records show 
that there is no indication of this in the enrollees records. Based on this information, we decided that Medicare 
rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a GeneSight Psychotropic Assay (81479) provided on June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gastroesophageal reflux test provided on October 13, 2022. 
 
You asked the Plan to pay for the gastroesophageal reflux test. You say that the services were medically 
necessary. The Plan denied your request. The Plan says with the information we have, we cannot determine 
how the member came to the servicing provider, or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the gastroesophageal reflux test have been met. Therefore, we decided that the Plan does not have to pay for a gastroesophageal reflux test provided 
on October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management service by a 
physician or other qualified health care professional services coded 99441 provided on September 14, 2022. 
 
You asked the Plan to pay for the telephone evaluation and management service by a physician or other 
qualified health care professional services. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99441 is not supported in the medical record. Specifically, the claim submitted is a 
facility claim reported with TOB (type of bill) 0711, Revenue code 0521, and CPT 99441. RHCs and FQHCs 
may bill the Telehealth originating site facility fee on a RHC or FQHC claim under revenue code 0780 and 
HCPCS code Q3014. This means the claim is not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of the telephone evaluation and management service by a physician or other 
qualified health care professional services have not been met. Therefore, we decided that the Plan does not 
have to pay for the telephone evaluation and management service by a physician or other qualified health care 
professional services coded 99441 provided on September 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 6, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 13, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 6, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, chest (71045) provided August 
22, 2022. 
 
You asked the Plan to pay for the diagnostic service. You say that please review the claim as it was denied 
incorrectly. The Plan denied your request. The Plan says the procedure code is inconsistent with the modifier 
used. 
 
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 find that CPT code 71045 is not supported in the medical record. Specifically, the enrollee's 
claim history indicates that the enrollee was incarcerated at the time. According to CMS Policy, services 
rendered to incarcerated members are not payable. A facility claim for the same date of service has been 
received with a discharge status indicating that the member was incarcerated. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided 
that the Plan does not have to pay for the radiologic examination, chest (71045) provided August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on July 
15, 2022. 
 
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 Current Procedural Terminology (CPT) code 99223 (1 Units) remains 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 code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit."  
We asked our coder 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 reviewer found that there is a more appropriate code 
to report for the services provided. The record does support a comprehensive history and exam. However, the 
record does not support medical decision making (MDM) of high complexity. The MDM consists of 
monitoring and continuing the patient's current regime with some medication changes, following 
neurosurgery's recommendations, and PT and OT. This does not support high medical decision making; it 
supports medical decision making of moderate complexity. 
 
We looked at this coder'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 initial hospital care (procedure code 99223) rendered on July 15, 2022.