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

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on May 19, 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 the 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 date of service inconsistent with Medicare rules governing laboratory services. The records submitted show the specimen were collected on April 29, 2022, and it was received on May 5, 2022. The provider billed 81455 with DOS May 19, 2022, and Place of Services (POS) 81. While the test was billed on the date the report was signed, there is no documentation that the specimen was collected from a hospital outpatient during an encounter. In fact, the claim form listed the place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. The exceptions to the general rules does not apply as the provider documented that the specimen was not obtained during a hospital outpatient encounter and was obtained by the laboratory directly. Additionally, the test has not been cleared or approved by the Food and Drug Administration and did not meet the requirements of NCD 90.2. There is no documentation of recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. There is no documentation that the enrollee had decided to seek further cancer treatment (e.g., therapeutic chemotherapy).

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 as billed due to issues with the POS code reported, the dates of service reported and a lack of documentation to the enrollee had a qualifying diagnosis for this testing. 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 May 19, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for testing services provided to the enrollee on December 22, 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 met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan notes while they agree that an exception to the date of service rule likely applies in this case. However, this is an administrative determination for billing and is not based on clinical criteria for medical necessity. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service. The specimen was collected during an outpatient encounter.
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 as billed due to an error with the POS code reported. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for testing services provided to the enrollee on December 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve the inpatient hospital admission. You say that the records provided support 
the need for an inpatient hospital admission. The Plan denied your request. The Plan says the procedure is 
currently approved as an ambulatory procedure. The Plan says that there is no documentation provided to 
support the expectation the enrollee will require an inpatient stay for greater than 2 midnights. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   

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 the inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for coverage of an inpatient admission 
are met in this case. Our physician reviewer found the shoulder surgery may be safely performed with a 48-
hour observational stay. An inpatient stay is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service March 17, 
2022. 
 
You asked the Plan to pay for procedure code 0245U. You say that the testing was medically necessary and 
should be paid. The Plan denied your request. The Plan says payment for code 0245U is bundled into payment 
for code 0018U. 
 
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 0245U 
is a column II code to column I code 0018U. 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 0245U billed for date of service March 17, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for therapy services provided to the enrollee on August 17, 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 that the primary insurance denied, and the claim was paid correctly. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
The plan has not substantiated their denial in a meaningful way in this case. Therefore, we decided that the Plan 
has to pay for therapy services provided to the enrollee on August 17, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on October 19, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you broke a tooth and 
needed to get the rest of it removed. You also say that you were sent to a dentist that did not provide 
extractions, and you found an oral surgeon near you who accepted your plan. The Plan denied your request. 
The Plan says your benefit for the requested item or service has already been exhausted. The Plan also says that 
you did not contact the Plan prior to the date of service to verify benefits and provider eligibility. 
 
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 September 29, 2022. 
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation 
(D0140) provided on October 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gum surgery (D4266), a surgical revision (D4268), surgical 
extraction (D2750), bone replacement graft (D7953), sutures (D7911), and regional block anesthesia (D9211), 
provided on June 8, 2022. 
 
You asked the Plan to pay for dental services. You say that these services should be covered. The Plan denied 
your request. The Plan says the denied services are not covered. 
 
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 pay for gum 
surgery (D4266), a surgical revision (D4268), surgical extraction (D2750), bone replacement graft (D7953), 
sutures (D7911), and regional block anesthesia (D9211), provided on June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim crown (D2799) for tooth #4 and #6. 
 
You asked the Plan to pre-approve an interim crown (D2799) for tooth #4 and #6. You say that tooth # 6 has 
extensive decay visible on the x-ray. You also say that after the decay is removed, a crown is the best treatment 
option because most of the tooth structure will be gone, and the tooth will be weak and potentially break if it is 
not supported by a crown. The Plan denied your request. The Plan says an interim crown (D2799) is a non-
covered code per the EOC. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 an 
interim crown (D2799) for tooth #4 and #6.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory tests (82306, 82607, 82728, 83540, 83550 and 
84153) performed on August 2, 2022. 
 
You asked the Plan to pay for laboratory tests. You say that these services were necessary and were ordered by 
the enrollee's physician. The Plan denied your request. The Plan says these services were provided as screening 
tests and are not covered for the diagnoses indicated on this claim. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, laboratory tests, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
laboratory tests (82306, 82607, 82728, 83540, 83550 and 84153) performed on August 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blepharoplasty of the left eye (15823). 
 
You asked the Plan to pre-approve a left-eye blepharoplasty. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a left-eye blepharoplasty. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation of the marginal reflex distance (MRD) being less than 
2 mm on the left side. The photos provided do not demonstrate that the excess skin is overhanging the eyelid 
margin. There are no visual fields provided to demonstrate a superior visual field defect due to the left upper 
eyelid. There is no documentation of a Hering's effect such that surgery on the right side will affect the left side in question. 
 
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 left-eye blepharoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a blepharoplasty of the left eye (15823).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 16, 2022, billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 81355, 81406 and 81407. 
 
You asked the Plan to pay for the genetic testing billed. You say that these tests are supported in the medical 
record. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the 
claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 16, 2022, billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 81355, 
81406 and 81407.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services August 10, 2022, through 
August 27, 2022. 
 
You asked the Plan to pay for skilled nursing facility services. You say that the services in question are 
coverable under the Medicare act. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for skilled nursing facility services August 10, 2022, through 
August 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and transfer 
handles for a Corpus 3G seat (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the denial of these particular items 
does not make the base or any other accessories unusable nor does it change the HCPC code or group 
appropriate for use to meet this enrollee's needs. The items in question are not an integral part of the base, thus 
a split decision should be possible. The Plan denied your request. The Plan says the seat elevator does not serve 
a primary medical purpose and is statutorily non-covered. The Plan also says transfer handles for the requested 
PWC seat do not primarily serve a medical purpose and therefore cannot be covered as reasonable and 
necessary under the Medicare criteria. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and transfer handles 
for a Corpus 3G seat (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided from August 30, 
2022, through August 31, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; 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 patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 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 found CPT code 99233 on August 
30, 2022, and August 31, 2022, does not meet criteria for billing or reimbursement consideration. The medical 
records provided does not include sufficient documentation to validate that a subsequent hospital care 
evaluation and management code requires two out of these three key components: a detailed interval history, a 
detailed examination and medical decision making of high complexity was the service provided on August 30, 
2022, therefore, this service 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (99233) provided from August 30, 2022, through August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening prostate specific antigen tests (G0103) 
provided April 26, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you received a lot of literature from the Plan 
to take a lot of tests, which said they were all covered and called preventable maintenance, so that is what you 
did. The Plan denied your request. The Plan says this cost sharing was charged correctly. The maximum 
amount covered has been paid by the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is no coinsurance, copayment, or deductible for an annual PSA test.  
 
The Plan says you must pay $148.48 for the laboratory service. Based on the Plan contract, however, there is 
no coinsurance, copayment, or deductible for an annual PSA test for the laboratory service. The Plan has not provided any documentation showing that any prostate screening services was previously paid. for the 
laboratory service. Therefore, we decided that the Plan does not have to pay for the screening prostate specific 
antigen tests (G0103) provided April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of sclerosant (36471), ultrasonic guidance for 
needle placement (76942), and endovenous ablation therapy (36482). 
 
You asked the Plan to pre-approve the sclerosant injection and ultrasonic guidance. You say that the enrollee 
has previously tried compression stockings. You say that they did not resolve the enrollee's symptoms. You 
also say that the enrollee elevates their legs as able and walks for exercise. The Plan denied your request. The 
Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are less than 
4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative therapy. 
Medicare includes payment for the ultrasound guidance in the payment for endovenous ablation procedures. 
 
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 the sclerosant injection and ultrasonic 
guidance. Our reviewer says that the requested sclerosant injection and ultrasonic guidance are not medically necessary. Our physician reviewer found the provided documentation does not support that the enrollee trialed 
all of the conservative therapy components. The reviewer found that the enrollee would need to have treatment 
of the vein that is showing reflux before being treated to remove the other enlarged veins. The reviewer also 
found there is no documentation in the medical record why ultrasound guidance for needle placement is 
medically necessary. Therefore, the reviewer found that the requested injection and ultrasonic guidance are not 
medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the sclerosant injection and ultrasonic guidance have not been met. Therefore, 
we decided that the Plan does not have to pre-approve injection of sclerosant (36471), ultrasonic guidance for 
needle placement (76942), and endovenous ablation therapy (36482).