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

 
We decided that the Plan does not have to pay for procedure codes 93308, 93325, and 93321 billed for date of 
service September 16, 2022. 
 You asked the Plan to pay for procedure codes 93308, 93325, and 93321. You say that you have provided 
medical re4cords to support payment. The Plan denied your request. The Plan says payment for codes 93308, 
93325, and 93321 is bundled into payment for code 93306. 
 
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 codes 
93308, 93325, and 93321 are column II codes to column I code 93306. 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 codes 93308, 93325, and 93321 
billed for date of service September 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided during mastectomy 
provided on April 4, 2022. 
 
You asked the Plan to pay for the assistant surgeon services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says although skilled, students are not recognized for payment. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
 
 In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services 
provided during mastectomy provided on April 4, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit and electrocardiogram 
provided on May 6, 2022. 
 
You asked the Plan to pay for the emergency department visit and electrocardiogram. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says this claim is a duplicate of a 
previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 9, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for the emergency department visit and 
electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for the 
emergency department visit and electrocardiogram provided on May 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72080 billed for date of service October 3, 
2022. 
 
You asked the Plan to pay for procedure code 72080. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 72080 is bundled into payment for 
code 72070. 
 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 72080 
is a column II code to column I code 72070. 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 72080 billed for date of service October 3, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral (0627T). 
 
You asked the Plan to pre-approve the injection services. You say that based on the enrollee's clinical condition 
and review of the supporting documentation. The Plan denied your request. The Plan says there is insufficient 
high-quality evidence to support percutaneous injection of allogeneic cellular/tissue-based products for treating 
discogenic pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. 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 pre-
approve percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral 
(0627T).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on June 21, 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 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 (POS) 81, indicated an independent laboratory took the sample. However, the specimen was
collected during an outpatient encounter. 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. Providers must report services with the appropriate code. In this case, the claim was
not billed with the appropriate POS code. 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 June
21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit provided on  
September 1, 2022. 
 
You asked the Plan to waive the coinsurance for the office visit. 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 a 30% 
coinsurance for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay a 30% coinsurance for the office visit. This 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 coinsurance for an office visit provided on September 1, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the physicians services provided from August 24, 2021 to  
August 30, 2021. 
 
You asked the Plan to pay for the physicians services. You say that the provider taxonomy is billed correctly. 
The Plan denied your request. The Plan says that the taxonomy is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare rule or a coding rule to 
substantiate the denial. Therefore, we decided that the Plan has to pay for the physicians services provided 
from August 24, 2021 to August 30, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of any lymphedema extending onto the chest, trunk, and/or 
abdomen. 
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records do not document any physical examination findings showing lymphedema of the chest, 
trunk, or abdomen. As records do not document lymphedema of the chest, trunk or abdomen or a four-week 
trial and failure of a standard pneumatic compression pump, then it cannot be said that the enrollee has unique 
characteristics that would indicate a segmented pump over a standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667).
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 these services. You say that this claim should be paid 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 information. The Plan noted that the claim form
listed the 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. Therefore,
the date of service for a clinical laboratory test or the technical component of physician pathology service
would have to be the date the specimen was collected based on the POS documented on the claim form. The
pathology report included in the submission documented the tumor maximum diameter 3.0 with negative
nodes. There is no documentation that the enrollee patient has either recurrent, relapsed, refractory, metastatic,
or advanced stage III or IV cancer; and has not been previously tested with the same test using NGS for the
same cancer genetic content, and has decided to seek further cancer treatment (e.g., therapeutic chemotherapy).
The pathology report included in the submission documented the tumor maximum diameter 3.0 with negative
nodes. Effective for services performed on or after March 16, 2018, the Centers for Medicare & Medicaid
Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory test is
reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement
Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following
requirements are met: a. Patient has: I. either recurrent, relapsed, refractory, metastatic, or advanced stage III or
IV cancer; and II. not been previously tested with the same test using NGS for the same cancer genetic content,
and III. 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 was submitted with POS code errors and the medical records
lacked the diagnoses required for coverage of this testing. 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 May 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure coded as 64628 and 64629. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are appealing the wrongful denial 
for Intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept procedure. The 
Plan denied your request. The Plan says this procedure is considered experimental and investigational as there 
is insufficient evidence in its safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Intracept procedure coded as 64628 and 64629.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ferumoxytol 510MG/17ML vial (Q0138). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 medication. Our physician reviewer 
found the Plan requires a trial of drug(s) Ferrlecit (sodium ferric gluconate) or Infed (iron dextran injection 
USP) or Venofer (iron sucrose injection) and there is no indication that the enrollee has tried and failed the 
required drug(s). Based on the medical records provided and the Medicare-approved major drug compendia 
there is no indication that the Plan's required drug(s) would likely be less effective and/or likely have adverse 
effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ferumoxytol 510MG/17ML vial (Q0138).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing (81455) provided to the enrollee on April 6, 2022.
You asked the Plan to pay for the laboratory testing. You say that this test was necessary and is supported in the medical record. The Plan denied your request. The Plan says that the provider documented that the specimen was not obtained during a hospital outpatient encounter and was obtained by the laboratory directly.
The Plan must follow Medicare rules. Medicare rules say that the general rule for the date of service (DOS) policy for either a clinical laboratory test or the technical component of physician pathology service is to bill the date the specimen was collected as the date of service. Maximus overturned the Plan's denial. The Plan requested a reopening stating that the specimen was obtained in a laboratory and has the incorrect date of service on the claim form. The claim shows a Place of Service of an independent laboratory. The rules state that the date of service submitted on the claim form must be the date the specimen was collected if the specimen was collected in a laboratory. The specimen was collected on March 29, 2022, but the date of service on the claim form was April 6, 2022. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing (81455) provided to the enrollee on April 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for group psychotherapy and an office visit provided from 
May 2, 2022 to May 5, 2022. 
 
You asked the Plan to pay for group psychotherapy and an office visit. The Plan denied your request. The Plan 
says in order for a facility to receive reimbursement for a Medicare member, the facility must be enrolled to 
participate in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Substance Abuse Facility is not 
eligible to participate in the Medicare program. 
 
 
 We looked at the file and Medicare rules. The provider at issue in this case is a Substance Abuse Facility. 
Medicare says that a Substance Abuse Facility is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for group psychotherapy and an office visit provided from  
May 2, 2022 to May 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Inogen portable oxygen concentrator 
 
You asked the Plan to pre-approve portable oxygen concentrator. You say that please consider approving this 
as the enrollee is in much pain and dragging the tank around is increasing their chronic obstructive pulmonary 
disease and arthritis. The enrollee deserves to be comfortable for the remaining time of their life. The Plan 
denied your request. The Plan says this request does not meet the guidelines for coverage. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has portable oxygen concentrator. The portable oxygen concentrator serves the 
same purpose as portable oxygen concentrator. Also, DME and medical supplies prescribed primarily for the 
convenience of the enrollee or the enrollee's family are not covered, including duplicate DME and medical 
supplies for use in multiple locations or any DME or medical supplies used to assist a caregiver. Therefore, we 
decided that the Plan does not have to pre-approve an Inogen portable oxygen concentrator
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Nodify CDT test (81599) provided June 16, 2022.
You asked the Plan to pay for this testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says Medicare does not cover this testing. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed in the Medicare rules section, are not covered. The test given to the enrollee was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Plasma-based proteomic tests may be helpful for assessing risk of cancer in enrollees that have pulmonary nodules, but there is not enough research to show that these tests can improve health outcomes for these enrollees. In addition, clinical guidelines based on research do not recommend this testing. Therefore, proteomic screening is considered investigational for the evaluation of pulmonary nodules. There is not enough research to show that gene expression tests can improve health outcomes for enrollees with pulmonary nodules. In addition, clinical guidelines based on research do not recommend this testing. This means this testing is considered investigational for the evaluation of pulmonary nodules. Therefore, we decided that the Plan does not have to pay for Nodify CDT test (81599) provided June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need these items. The Plan denied 
your request. The Plan says the requested items are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 24, 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 this claim was billed with a
place of service (POS) code of 81, which indicates the specimen was taken by the independent lab. However,
the medical records show the specimen was taken during and outpatient encounter and not by the independent
lab. Therefore, the POS code is incorrect.
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 was
billed with an inappropriate POS code. 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 March
24, 2022.