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

 
We decided that the Plan does not have to pay for lab services provided on July 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 31, 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 Medicare billing criteria are 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 the billing guidelines 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, which is not what is stated in the records or the on the claim.
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 was denied for errors involving the specimen collection date and the billed service date. 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 January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on September 17, 2021.
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 Medicare billing criteria were not met.
Maximus overturned the Plans denial stating the service was ordered by a contract provider. The Plan requested a reopen and stated the issue was the claim submitted had data element errors based on Medicare guidelines for specimen collection. The Plan stated that 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. Medicare non-coverage applies to both contracted and non-contracted providers and cannot be overridden by plan directed care. The billed dates versus the specimen collection dates do not meet these criteria.
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 billing errors involving the dates the specimen was reported to have been collected. 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 September 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Privigen. 
 
You asked the Plan to pre-approve Privigen. You say that the requested infusion services will help treat the 
enrollee's condition and that the chart notes provided support its medical necessity. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.   
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 Privigen. Our reviewer says that the 
requested drug is not considered medically reasonable and necessary in this case. Our physician reviewer found 
there is no report of recurrent infections and IgG levels all greater than 200. The use of Privigen is not FDA-
approved for the enrollee's diagnosis. The enrollee does not have documentation of recurrent infections caused 
by encapsulated bacteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Privigen have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Privigen.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded 20553 provided on June 20, 
2022. 
 
You asked the Plan to pay for the injection 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. 
 In this case, the CPT Code Manual definition of code 20553 is injection(s); single or multiple trigger point(s), 3 
or more muscles. 
 
We find that CPT code 20553 is not supported in the medical record. Specifically, the medical records indicate 
that the injection services provided were for one or two muscles, not three as billed This means there is a more 
appropriate code to be billed for these services. Based on this information, we decided that Medicare rules for 
coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay 
for the injection services coded 20553 provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 16, 
2022. 
 
You asked the Plan to pay for an evaluation. You say that you disagree with the denial of a limited oral 
evaluation. 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 August 9, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
August 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve the requested service. You say that a new chair is more cost effective. The 
Plan denied your request. The Plan says the item is not covered by Medicare or the Plan. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
We looked at the file and the rules. The item at issue does not serve a purpose that is primarily medical in 
nature. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) for tooth number 
30. 
 You asked the Plan to pre-approve a porcelain/ceramic crown (D2740) for tooth number 30. You say that you 
are appealing with supporting records. The Plan denied your request. The Plan says your dental plan only 
covers base metal crowns for your molars. 
 
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, a porcelain/ceramic crown (D2740) for 
molar teeth are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve a porcelain/ceramic crown (D2740) for tooth number 30.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient psychotherapy services provided to the enrollee on January 31, 2022.
You asked the Plan to pay for the outpatient psychotherapy services. You say that this should be paid for. The Plan denied your request. The Plan says that there was no documented contact with the attending/primary care physician.
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient psychotherapy services have not been met. Specifically, the record does not include documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. Therefore, we decided that the Plan does not have to pay for the outpatient psychotherapy services provided to the enrollee on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on August 1, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 you must pay $45 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $45 copayment for office visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. 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 copayment for office visit provided on August 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that this would help enrollee transition to home 
following repair of a hip fracture. The enrollee will benefit from additional skilled services. The Plan denied 
your request. The Plan says this is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found The enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150-59, 87481-59, 87491-59, 87591-59, 
87798-59, 87640-59, 87653-59, 87651-59, 87661-59, and 87641-59 billed for date of service February 22, 
2022. 
 
You asked the Plan to pay for procedure codes 87150-59, 87481-59, 87491-59, 87591-59, 87798-59, 87640-59, 
87653-59, 87651-59, 87661-59, and 87641-59. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment for code 87150 is bundled into payment for code 87500. 
 
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 87150 
is a column II code to column I code 87500. Codes 87481, 87491, 87591, 87798, 87640, 87653, 87651, 87661, 
and 87641 are column II codes to column I code 87150.  
 
This claim has not been billed with an appropriate modifier to bypass the edit. The -59 modifier is not 
supported as a separate and distinct procedural service. 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 codes 87150-59, 
87481-59, 87491-59, 87591-59, 87798-59, 87640-59, 87653-59, 87651-59, 87661-59, and 87641-59 billed for 
date of service February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for actinotherapy provided on April 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the actinotherapy. You say that medical records were submitted to support 
medical necessity. The Plan denied your request. The Plan says the provider is out-of-network, and a PCP 
referral was not obtained prior to services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for actinotherapy provided on April 6, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the technical component (TC) of neuromonitoring services. 
 
You asked the Plan to pay for the TC of neuromonitoring services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says payment for these 
neuromonitoring services must be requested from the hospital. 
 
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
 
Although these services may be appropriate, payment for them is made to the hospital which must then furnish 
these services either directly or under arrangements. As such, separate Medicare payment cannot be made for 
the services at issue. Therefore, we decided that the Plan does not have to pay for the technical component (TC) 
of neuromonitoring services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the $10 copayment charged for a diagnostic prostate test provided on January 17, 2022.
You asked the Plan to waive this copayment. You say that this was a screening and should be no charge. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans denial for insufficient records in the case file. The Plan requested a reopen and provided records to show this was not a screening and your physician ordered this as a diagnostic test.
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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 copayment for outpatient diagnostic tests. You have been asked to pay the correct amount based on your contract with the Plan.
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 copayment charged for a diagnostic prostate test provided on January 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment provided on February 3, 2022. 
 
You asked the Plan to pay for the provided services. You say that you were put on oxygen during your hospital 
stay. The Plan denied your request. The Plan says the provider does not participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
We looked at the file and the rules. A review records indicates that the provider at issue is not enrolled in the 
Medicare program. Therefore, we decided that the Plan does not have to pay for the oxygen equipment 
provided on February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the reports attached support these services. The Plan 
denied your request. The Plan says there is no prior authorization on file for the services rendered. Services can 
be obtained from an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on July 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of an impacted tooth (D7230). 
 
You asked the Plan to pre-approve removal of an impacted tooth. You say that the service is necessary, and you 
want the Plan to cover it. The Plan denied your request. The Plan says the service at issue is not a covered 
benefit. 
 
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 pre-approve 
removal of an impacted tooth (D7230).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 23430 billed for date of service May 16, 
2022. 
 
You asked the Plan to pay for procedure code 23430. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 23430 is bundled into payment for code 23472. 
 
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 23430 
is a column II code to column I code 23472. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 23430 billed for date of service May 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a stress test and an ECG provided on 
August 18, 2022. 
 
You asked the Plan to waive the copayments for a stress test and ECG. You say that this should be covered. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 you must pay $200 
copayment for Advanced imaging services.  
 
You have been asked to pay $43.79 which is less than the standard $200 copayment for a stress test and ECG. 
This item/service falls within the Advanced imaging services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. 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 copayments for a stress test and an ECG provided on August 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70544 billed for date of service July 22,
2022.

You asked the Plan to pay for procedure code 70544. You say that this service was medically necessary. The
Plan denied your request. The Plan says payment for code 70544 is bundled into payment for code 70553.

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 70544
is a column II code to column I code 70553. 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 70544 billed for date of service July 22, 2022.