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

 
We decided that the Plan does not have to pre-approve sclerotherapy for multiple veins (36471) and single 
veins multiple times (36470 x3). 
 
You asked the Plan to pre-approve sclerotherapy for multiple veins (36471) and single veins multiple times 
(36470 x3). You say that the enrollee has chronic venous insufficiency and continues to have pain in the lower 
extremities associated with cramps and discomfort. You say that the enrollee has been compliant with 
conservative treatment, but her symptoms persist. You say that the enrollee is requested for Varithena of the 
right medial and lateral thigh tributaries, and right anterior calf tributaries as well as Varithena of the left lateral 
thigh and lateral calf tributaries. The Plan denied your request. The Plan says the codes which remain in dispute 
are not medically necessary, as the 2 approved units of sclerotherapy cover multiple veins for each of the 
enrollee's legs, and the additional requested codes exceed the enrollee's medical need. 
 
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 sclerotherapy for multiple veins 
(36471) and single veins multiple times (36470 x3). Our reviewer says that the requested services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the documentation 
does not meet coverage criteria and does not support the medical necessity of additional venous procedures. 
The Plan has approved procedures that provide for sclerotherapy of multiple veins on each leg.  There would be 
no medical need to bill instead as multiple instances of sclerotherapy of individual veins.  Furthermore, coverage criteria and medical necessity criteria require that the enrollees symptoms be due to the varicose 
veins in question.  The enrollee has a history of peripheral artery disease (PAD) and claudication, and leg 
cramping is documented despite venous intervention and compression stockings.  The medical record 
documentation does not adequately establish satisfactory arterial perfusion to the lower extremities with this 
history and number of PAD risk factors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sclerotherapy for multiple veins (36471) and single veins multiple times (36470 
x3) have not been met. Therefore, we decided that the Plan does not have to pre-approve sclerotherapy for 
multiple veins (36471) and single veins multiple times (36470 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction, erupted tooth or exposed root (D7140 x6). 
 
You asked the Plan to pre-approve the extractions. You say that you need the extractions approved. The Plan 
denied your request. The Plan says this service is not medically necessary. 
 
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. The Plan covers the 
extractions when the services are medically necessary and reasonable.  
 
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 extractions. Our reviewer says that 
the requested service is not medically necessary. Our physician reviewer found the documentation indicates 
that the tooth numbers of the teeth to be extracted were not indicated. This is a required by the insurance carrier 
for documentation of services rendered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the extractions have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an extraction, erupted tooth or exposed root (D7140 x6).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional home health aide visits (G0156). 
 
You asked the Plan to pre-approve additional home health services. You say that you are requesting 
reconsideration because you cannot take care of yourself, and your wife is unable to assist you. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health services. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
records do not show that skilled nursing services are required to effectively provide treatment, care, and/or 
services in order to improve your condition, or to establish/perform a maintenance program to maintain your 
condition and/or prevent deterioration. The records do not show that skilled therapy services will be required to 
effectively provide treatment, care, and/or services in order to improve your level of function, or to 
establish/perform a maintenance program to maintain your level of function and/or prevent deterioration 
beyond the approved visits. The documentation does not reveal that you require skilled therapy beyond the 
approved visits or skilled nursing services. The services do not meet the definition of home health aide services 
per Section 50.2. The requested home health aide services are not reasonable and necessary to the treatment of 
your illness or injury by the skilled professional staff. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve ten (10) additional home health aide visits (G0156).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99233 and 99232 provided from May 12, 2022, to 
May 16, 2022. 
 
You asked the Plan to pay for codes 99233 and 99232. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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. 
 
The CPT Code Manual definition of code 99232 is subsequent hospital care, per day, for the evaluation and 
management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused 
interval history; An expanded problem focused examination; Medical decision making of moderate 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 responding inadequately to therapy or has developed a minor complication. Typically, 25 
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 codes 99233 and 99232. Our reviewer says that the 
documentation does not support the codes billed. Our reviewer found the enrollee was admitted with nausea, 
vomiting, and dehydration. The medical records submitted did not support a detailed interval history and 
medical decision making of high complexity. Therefore, code 99233 is not supported. The medical records 
submitted did not support an expanded problem focused interval history or an expanded problem focused 
examination. Therefore, code 99232 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 99233 and 99232 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 99233 and 99232 provided from May 12, 2022, to May 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound of the head and neck 
performed on May 25, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you think that the copayment for 
this service is too high. 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 $130 
copayment for Medicare-covered radiological diagnostic services, which includes ultrasounds, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic). 
 
You have been asked to pay $130 copayment for the ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the ultrasound of the head and neck performed on May 25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 additional home health visits. 
 
You asked the Plan to pre-approve home health services. You say that home health services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that you have 
a stable wound with a capable trained care giver. The wound does not require continued skilled nursing 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 18 additional home health visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 88305 billed for date of service September 28, 2021.

You asked the Plan to pay for procedure code 88305. You say that you were not told that this expense would not be covered. The Plan denied your request. The Plan says payment for code 88305 is bundled into payment for code G0416.

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 88305 is a column II code to column I code G0416. 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 88305 billed for date of service September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from February
3, 2022, to February 16, 2022.
You asked the Plan to pay for this claim. 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 overturned the Plans
denial for insufficient information in the case file The Plan requested a reopen and provided additional
information. The Plan noted that the medical records were inconsistent with the serviced billed and the
physician did not sign and date the records until after the claim was submitted. This is inconsistent with
Medicare billing requirements for documentation.
The Plan is correct in this case. 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 this claim have been met. The medical
record submissions are inconsistent and do not show the appropriate documentation was present prior to the
claim being filed. Therefore, we decided that the Plan does not have to pay for home health services provided
to the enrollee from February 3, 2022, to February 16, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you have exhausted your SNF benefit for this period. Maximus overturned the Plan's denial based on medical necessity. The Plan requested a reopening stating that services were not denied based on medical necessity but that SNF services were denied because the enrollee's benefit was exhausted.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from March 3, 2022, through May 1, 2022, and May 5, 2022, through June 20, 2022. The Plan has covered 100 days of SNF care.
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a low dose computed tomography (LDCT) scan for lung cancer screening provided on June 7, 2022.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial for insufficient information.
The Plan requested a reopen and provided additional information. The Plan noted denied because the provider billed this service with an inappropriate diagnosis code. The medical records provided do not show the enrollee met the criteria required for payment. The claim this was billed with diagnosis code Z12.2 (Encounter for screening for malignant neoplasm of respiratory organs) which is not considered an appropriate diagnosis code for Low Dose Computed Tomography (LDCT) as per the Medicare guidelines.
The Plan is correct in this case. 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. Medicare has specific coverage criteria for the imaging provided. There is insufficient information in the record which show the required coverage criteria were met at the time of service. Therefore, we decided that the Plan does not have to pay for a low dose computed tomography (LDCT) scan for lung cancer screening provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay additional reimbursement for dental services (D0210 and D0120) provided on August 3, 2022.
You asked the Plan to pay additional reimbursement for these services. The Plan denied your request. Maximus upheld the Plans decision. You requested an ALJ hearing. The ALJ remanded the case back to Maximus because they felt the Plans denial was not explained to you appropriately. Maximus requested additional information from the Plan at the request of the ALJ. Maximus requested a breakdown from the Plan of the $228 cost share being charged. The Plan returned additional information which states the dental x-rays provided coded as D0210 required payment of $160, because this type of imaging has a frequency limitation and was exhausted on June 6, 2022. The Plan states for the intraoral images coded as D0120, the Plan paid $28 to the provider as that was the negotiated rate, leaving a balance of owed by you of $68.
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 imaging services coded as D0210 were not available for coverage at the time of service due to prior exhaustion. For the imaging services coded as D0120, the Plan paid per the negotiated rate, leaving the balance as your cost share. Therefore, we decided that the Plan does not have to pay additional reimbursement for dental services (D0210 and D0120) provided on August 3, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 10, 2022.
You asked the Plan to pay this claim. 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 denied because this service was billed with an inappropriate Place of Service code of 22 for an outpatient setting. The medical records show the enrollee was in inpatient status from April 29, 2022, to May 12, 2022. The Plan submitted documentation to confirm this.
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, this claim could not be paid as billed due to an error with the POS code billed. Medicare rules for coverage of this service were not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on May 10, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for Claim A.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient claim information in the case file. The Plan requested a reopen and provided additional information. The Plan demonstrated that Claim A denied because it was determined the Plan previously paid for this service under another claim. The Plan demonstrated that these services were paid under Claim B to the same provider group and that both billing physicians practice under the same taxonomy code of 207RG0100X, Internal Medicine, Gastroenterology.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems.
Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for Claim A.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic services (93000) provided to the enrollee on March 15, 2022, under Claim A.
You asked the Plan to pay for services billed under Claim A. 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 stated that Claim A denied because the Plan previously paid for this service under another Claim B. The Plan states the medical records do not support why this procedure had been billed and or rendered twice on the same day. The Plan states both providers are in the same billing group with the same NPI designation.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems.
Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for diagnostic services (93000) provided to the enrollee on March 15, 2022, under Claim A.