Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic evaluation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an orthopedic evaluation. You say that this doctor is the only one in the area 
that can provide this service. The Plan denied your request. The Plan says the services have been requested 
from an out-of-network provider. In-network providers are available and offer robotic hip surgery. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an orthopedic evaluation to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory service (83036) provided on May 19, 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 the Medicare billing criteria were not as this was a suspected duplicate. Maximus
overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan states
that this denied a suspect duplicate service because the Plan already paid for this service under another claim.
The appealed claim was billed inappropriately and did not support why this procedure had been rendered twice
on the same day. This claim denied for "suspect" duplicates and not "exact" duplicates. The provider needed to
bill with Modifier 26 to show the service provided was the reading and interpreting of the results of a
diagnostic and/or laboratory service; or with Modifier 91 to show the laboratory test(s) were performed more
than once on the same day on the same patient. According to the Medicare Claims Processing Manual, Chapter
1, General Billing Requirements, Section 120, Detection of Duplicate Claims, explains "The claims processing
systems contain edits which identify exact duplicate claims and suspect duplicate claims. All exact duplicate
claims or claim lines are auto denied or rejected (absent appropriate modifiers). Suspect duplicate claims and
claim lines are suspended and reviewed by the claims administration contractors to decide to pay or deny the
claim or claim line." Section 120.3, Suspect Duplicates, states "Suspect duplicates are claims or claim lines that
contain closely-aligned elements sufficient to suggest that duplication may be present and, as such, require that
the suspect claim be reviewed.
Suspect duplicate edits can be hard coded in the system or local edits set up by Medicare contractors." And
"The criteria for identifying suspect duplicate claims submitted by physicians and other suppliers are not
published and vary according to the type of billing entity, type of item or service being billed, and other
relevant criteria. The denial of claim as a duplicate of another claim may be appealed when the denial is based
on criteria other than those specified above for exact duplication." Therefore, the Plan could not pay this claim
as billed.
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 the claim
submitted cannot be paid as billed due to the omission of the required modifier. Medicare rules for coverage of
these services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory
service (83036) provided on May 19, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on July 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on July 20, 2021.  
 
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 services (88307) provided on October 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
service. 
 The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one 
previously processed and paid by the Plan. Duplicate claims are not payable. 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 the services (88307) provided on October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) or pay more 
for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), bitewing x-rays (D0273), and 
prophylaxis (D1110) provided on February 9, 2022 by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the additional intraoral periapical x-ray and to pay more for the periodic oral 
evaluation, first intraoral periapical x-ray, bitewing x-rays, and prophylaxis. You say that these are first x-rays 
you have had this year, and in view of qualified dentists listed as providers, the Plan should have paid more on 
this claim. The Plan denied your request. The Plan says your intraoral x-rays benefit has been satisfied and the 
frequency limitation has been exceeded. The Plan also says that these services were performed by a non-
participating provider, and you are responsible for any difference between the Maximum Allowable Fee and 
the amount the provider bills you for the services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, intraoral x-rays are limited to 1 
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) 
on February 9, 2022 and your intraoral x-rays benefit has been exhausted. You are also responsible for a 50% 
coinsurance for each periodic oral evaluation, first intraoral periapical x-ray, bitewing x-rays, and prophylaxis, 
plus the difference between the billed amounts and allowed amounts because these services were received 
OON. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray 
(D0230) or pay more for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), bitewing 
x-rays (D0273), and prophylaxis (D1110) provided on February 9, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 12, 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 are not met. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information. The Plan stated this claim denied because this service
was already paid under another claim to the same provider. The case file includes the appealed and referring
claims that show the provider has billed the exact same service under the same physician group, Pathology
Sciences Medical Group. These claims denied only for "suspect" duplicates and not "exact" duplicates.
According to the Medicare Claims Processing Manual, Chapter 1 - General Billing Requirements - Section
120 - Detection of Duplicate Claims, explains "The claims processing systems contain edits which identify
exact duplicate claims and suspect duplicate claims. All exact duplicate claims or claim lines are auto denied
or rejected (absent appropriate modifiers). Suspect duplicate claims and claim lines are suspended and
reviewed by the claims administration contractors to decide to pay or deny the claim or claim line." Section
120.3 - Suspect Duplicates, states "Suspect duplicates are claims or claim lines that contain closely-aligned
elements sufficient to suggest that duplication may be present and, as such, require that the suspect claim be
reviewed. Suspect duplicate edits can be hard coded in the system or local edits set up by Medicare
contractors." In addition, "The criteria for identifying suspect duplicate claims submitted by physicians
and other suppliers are not published and vary according to the type of billing entity, type of item or service
being billed, and other relevant criteria. The denial of claim as a duplicate of another claim may be appealed
when the denial is based on criteria other than those specified above for exact duplication." Therefore,
Medicare billing criteria were 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 cannot be paid as billed due to payment already made to this
provider for this service on a previous claim. Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual wellness exam provided on October 1, 2021.
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan
denied your request. The Plan says the annual wellness exam is covered at no charge once per year and this
benefit was exhausted on January 5, 2021. Maximus overturned the Plans denial as the records did not include
proof of payment for January 5, 2021. The Plan requested a reopen and provided the required information.
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 an annual wellness exam is covered at no charge once per year.
The records show you were provided coverage for an annual wellness exam at no charge for date of service
January 5, 2021. This benefit was not available for coverage on October 1, 2021. Therefore, we decided that
the Plan does not have to pay for an annual wellness exam provided on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (code D0150) or waive the 
coinsurance for the dentures (codes D5120 and D5110) you received on June 7, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam and to waive the coinsurance charged for the 
dentures. You say that because the dentist did the mold of your mouth incorrectly, you believe you should be 
refunded for these services. The Plan denied your request. The Plan says you were charged the correct 
coinsurance for the dentures.  The Plan says that you had already exhausted your benefit for the comprehensive 
oral exam earlier in the year, so you were not eligible for coverage of that service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan's benefit says that 
you are entitled to one comprehensive oral exam (code D0150) every three years. Records show that you had already received a covered comprehensive oral exam on February 5, 2021, so you were not eligible for another 
one on the date of service in question in this appeal.  In addition, your dental benefit clearly states that you pay 
50% coinsurance for dentures.  Your Plan has paid 50% of the allowed amount for the dentures, leaving you 
with the appropriate 50% coinsurance as your liability. 
 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (code D0150) and to 
waive the coinsurance for the dentures (codes D5120 and D5110) you received on June 7, 2021.  
 
Your complaint about the denture mold being made incorrectly is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the allograft for spine surgery only (20931) and osteotomy of 
spine (22224 and 22226) provided on June 7, 2021. 
 
You asked the Plan to pay for the allograft for spine surgery only (20931) and osteotomy of spine (22224 and 
22226). You say that the attached records should be forwarded to the correct department for processing. The 
Plan denied your request. The Plan says procedure codes 20931, 22224 and 22226 are not supported by the 
medical records submitted. 
 
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 20931 is allograft, structural, for spine surgery only (List 
separately in addition to code for primary procedure). The CPT Code Manual definition of code 22224 is 
osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar. The CPT Code 
Manual definition of code 22226 is osteotomy of spine, including discectomy, anterior approach, single 
vertebral segment; each additional vertebral segment (List separately in addition to code for primary 
procedure). 
 
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 allograft for spine surgery only (20931) and osteotomy of 
spine (22224 and 22226). Our reviewer says that the documentation submitted was reviewed and does not meet 
the criteria for coverage. Our reviewer found that the operative report describes autogenous bone marrow, 
therefore an allograft procedure cannot be verified. The operative report also does not describe osteotomy 
procedures per the NCCI Policy Manual. Therefore, these procedures cannot be verified. 
 
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 allograft for spine surgery only (20931) and osteotomy of spine (22224 and 
22226) have not been met. Therefore, we decided that the Plan does not have to pay for the allograft for spine 
surgery only (20931) and osteotomy of spine (22224 and 22226) provided on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 30 units of Kyprolis (J9047) discarded on July 14, 2020.
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 claim did not properly record the discarded drugs. Maximus overturned the Plans
denial. The Plan requested a reopen and provided additional information. The Plan states this claim was
submitted for J9047-JG x 30 units and J9047-JW, JG x 30 units. One unit of J9047 (carfilzomib, Kyprolis) is
equal to 1 mg. Per submitted medical administration records, patient received 30 mg (30 units) of Kyprolis
(J9047) for this date. Per CMS Medicare Claims Processing Manual, Chapter 17, Section 40 Discarded Drugs
and Biologicals, "Providers must record the discarded amounts of drugs and biologicals in the patient's medical
record." Medication wastage is not documented in the medical records; therefore, J9047-JW, JG x 30 units is
not supported.
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, we do not find his claim billed the discarded unit correctly based on the
required guidelines. Therefore, we decided that the Plan does not have to pay for 30 units of Kyprolis (J9047)
discarded on July 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 31525, 37600, and 43200 billed for date of 
service August 9, 2021. 
 
You asked the Plan to pay for procedure codes 31525, 37600, and 43200. You say that you have provided 
medical records to support payment of these codes. The Plan denied your request. The Plan says these codes 
are not supported by the medical record. 
 
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 31525 is Direct diagnostic laryngoscopy, with or without 
tracheoscopy, of a patient except a newborn.  The CPT Code Manual definition of code 37600 is Ligation of 
the external carotid artery.  The CPT code definition of code 43200 is flexible diagnostic esophagoscopy and 
transoral, including collection of specimen(s) by brushing or washing, where performed. 
 
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 procedure codes 31525, 37600, and 43200. Our reviewer 
says that these codes are not supported by the medical record. Our reviewer found for code 31525, a diagnostic 
laryngoscopy, would not be reported separately from the primary procedure of resection of mandible and 
orocutaneous fistula, and documentation does not support this procedure as a separate procedure. For code 
37600, a free myocutaneous flap was performed, but documentation does not support this procedure as a 
separate procedure. For code 43200, the operative report describes ligation of the superior thyroid artery for 
flap usage. In this case, this procedure would be inclusive to the primary procedure of myocutaneous free flap 
reconstruction. The documentation does not support this procedure as a separate procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 31525, 37600, and 43200 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 31525, 37600, and 43200 billed for date of 
service August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on December 28, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that prior authorization is the responsibility of 
the assisted living facility to obtain. The Plan denied your request. The Plan says the services were provided 
out-of-network and were not approved in advance. 
 
 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 the home health services provided on December 
28, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to waive the cost share of services provided on February 12, 2021.
You asked the Plan for these services. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says these services must be addressed under your Medicaid benefit. Maximus
overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says
that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included
documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually
eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid
may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal
care, and home- and community-based services). These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are
covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid
coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits.
Therefore, we decided that the Plan does not have to pay for these services under the Medicare benefit.
Therefore, we decided that the Plan does not have to waive the cost share for physician services provided on
February 12, 2021.