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

 
We decided that the Plan does not have to pay for lab services provided on February 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of 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 February 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J0702 provided on August 23, 2022. 
 
You asked the Plan to pay for procedure code J0702. You say that you would like the Plan to reconsider their 
denial of payment. 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 October 6, 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 procedure code J0702 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code J0702 provided on August 23, 
2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on February 10, 2022.
You asked the Plan to pay for these services. You say that this imaging 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. The Plan requested a reopen and provided additional claim information. The Plan noted that the provider is appealing the denial of procedure code 71045-26 (radiologic examination chest, professional component) provided on February 10, 2022. The Plan is submitted proof that both claims have the same 26 professional component modifier and neither have any bypass modifier indicating a repeat or separate and distinct service was performed. Therefore, the claims are considered duplicate.
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 claims submitted do not show a separate and distinct service from the previous billing. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing services provided to the enrollee on January 20, 2022.
You asked the Plan to pay for the testing services. You say that the testing meets criteria for coverage. The Plan denied your request. The Plan says that the specimen was collected in an outpatient facility.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing services provided to the enrollee on January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 25, 2022.
You asked the Plan to pay for this testing. 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. The Plan requested a reopen and provided additional information. The Plan noted that the claim was billed with a place of service code of 81, which would indicate the specimen was taken directly by the billing laboratory. However, the medical records show the specimen was taken by an outpatient facility and not the billing laboratory. Therefore, the claim cannot be paid 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 code. In this case, this claim could not be paid due to an error with the POS code 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 April 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator. You say that this item is needed so that you can return home from the hospital. The Plan denied your request. The Plan says this item is needed so that you can return home from the hospital.
Our Medical director looked at the case file and the reopen request. At issues is coverage for a home ventilator. Our Medical Director states that the case file does not contain documentation of trial and failure of BiPAP with backup rate and AVAPS. The documentation is insufficient to support that a home ventilator (E0466) is medically reasonable and necessary in this case. Our physician reviewer found that your condition did not meet Medicare criteria for a home ventilator.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Parkinson's fitness class received on February 1, 2022.
You asked the Plan to pay for the fitness class. You say that this was recommended by your neurologist. The Plan denied your request. The Plan says that the benefit is limited to participating locations only. Maximus overturned the Plan's decision because the Plan did not provide adequate documentation. The Plan requested a reopening with new information showing the facility was not a participating location.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's benefit includes access to group exercise classes at participating locations. The Plan's rules for coverage of gym benefits have not been met because this fitness class was not provided at a participating location. Therefore, we decided that the Plan does not have to pay for the Parkinson's fitness class received on February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided to the enrollee on July 14, 2021.
You asked the Plan to pay this claim. You stated this equipment was medically necessary. The Plan denied your request. Maximus overturned the Plans denial for insufficient information regarding the decision. The Plan requested a reopen and confirmed this was not denied for medical necessity. The Plan confirmed the claim did not include, at minimum, a 30 day billing end date for this rented item, which is required by Medicare. The Plan stated a corrected claim would be reviewed if submitted.
The Plan is correct in this case. The Plan must follow Medicare billing requirements. The rules state that any claim missing a data element will be denied.
The claim submitted is for rented equipment and therefore, would require a start and end date for the billing period billed. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided to the enrollee on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing services provided to the enrollee on May
19, 2022.
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed
for medical necessity. The Plan denied your request. The Plan says that the specimen was not collected at an
independent laboratory.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical
necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of
service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An
independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen
was not collected in an independent laboratory.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, this claim
cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing services
provided to the enrollee on May 19, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Liquid CDx (F1LCDx) testing provided
to the enrollee on April 17, 2022.
You asked the Plan to pay for the F1LCDx testing. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says that the specimen was obtained during a
hospital outpatient encounter.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical
necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of
service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An
independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen
was not collected in an independent laboratory.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, this claim
cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing
have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne Liquid
CDx (F1LCDx) testing provided to the enrollee on April 17, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing (0037U) provided
to the enrollee on May 31, 2022.
You asked the Plan to pay for the F1CDx testing. You say that this test was necessary and is supported in the
medical record. The Plan denied your request. The Plan says that this was not taken in a laboratory place of
service.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical
necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of
service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An
independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen
was not collected in an independent laboratory.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, this claim
cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing
have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx
(F1CDx) testing (0037U) provided to the enrollee on May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing (0037U) provided
to the enrollee on May 31, 2022.
You asked the Plan to pay for the F1CDx testing. You say that this is an FDA-approved test that is covered by
Medicare. The Plan denied your request. The Plan says that the claim did not include the required DEX Z-code.
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue,
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the
coverage status is listed in the DEXTM Diagnostics Exchange.
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier
was reported. Based on this information, we decided that Medicare rules for coverage of the F1CDx testing
have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx
(F1CDx) testing (0037U) provided to the enrollee on May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483, 80307) provided to the enrollee on January 5, 2022.
You asked the Plan to pay for the drug testing services. You say that these services were referred by the enrollee's treating physician and are supported as billed. The Plan denied your request. The Plan says that after multiple attempts to obtain information, none was received. Maximus overturned the Plan's denial for lack of documentation. The Plan requested a reopen and provided additional documentation showing records have been requested.
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 drug testing services have been met. Medical records were not provided in this case and the Plan provide documentation that records were requested multiple times. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483, 80307) provided to the enrollee on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided to the enrollee on January 31, 2022.
You asked the Plan to pay for the genetic testing. You say that Medicare has determined this testing to be reasonable and necessary for the management of the enrollee's condition. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the required unique identifier.
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier was reported. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided to the enrollee on January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing (0037U) provided to the enrollee on
August 19, 2021.
You asked the Plan to pay for the laboratory testing. You say that these services were necessary and are
supported in the medical record. The Plan denied your request. The Plan says that the specimen was collected
during an outpatient encounter.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical
necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of
service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An
independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen
was not collected in an independent laboratory.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, this claim
cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing (0037U)
provided to the enrollee on August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx test for Prostate Cancer (81479) provided to the enrollee on October 14, 2021.
You asked the Plan to pay for the testing. You say that this test can help predict the likelihood that prostate cancer will be found by a biopsy. The Plan denied your request. The Plan says that the specimen was collected in the physician office.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the SelectMDx test for Prostate Cancer (81479) provided to the enrollee on October 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for procedure code 75625 billed on March 24, 2022.
You asked the Plan to pay these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing guidelines. The Plan noted code 75625 is not supported by the medical records submitted. The operative report did not include documentation of an abdominal aortography by serialography with radiological supervision and interpretation; therefore, this code cannot be verified. Per the guidelines physicians should report the code that describes the procedure performed to the greatest specificity possible. In this case, the clinical documentation provided in the narrative operative report does not sufficiently describe or support the codes billed. Therefore, code 75625 cannot be verified There is no commentary on the usual abdominal aortogram findings (renal and/or mesenteric vessels). To cite the operative report; "A 5-French pigtail catheter was then advanced into the abdominal aorta, and abdominal aortography was performed." Per the National Correct Coding Initiative Policy Manual for Medicare Services, Revision Date January 1, 2022; in regard to the submitted (CPT) code of 75625, a local anesthetic is applied over the common femoral artery. The artery is percutaneously punctured with a needle and a guidewire is fed through the artery into the abdominal aorta. A catheter is threaded over the guidewire to the point of study and the guidewire is removed. Contrast medium is injected, and films are taken by serialography, producing a series of individual x-ray films. This code reports the radiological supervision and interpretation. Use a separately reportable code for the catheterization. For injection procedures, see 93567, which include imaging interpretation and report. If the abdominal plus bilateral iliofemoral vessels are studied, see 75630.
Contrast media may be reported with A4641, Q9951, Q9958-Q9967. This description was not documented in the operate report narrative.
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. This case involves an inappropriate billing of code 75625 which is not supported in the documentation and therefore is not payable.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 75625 billed on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for focal laser ablation provided on May 26, 2021 and 
May 27, 2021. 
 
You asked the Plan to reimburse you for focal laser ablation. The Plan denied your request. The Plan says the 
claim is past the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for focal laser ablation was not filed until September 27, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to reimburse you for focal laser ablation provided on May 26, 2021 and 
May 27, 2021.