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

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport and ground mileage provided on August 30, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the requested ambulance transport. The Plan denied your 
request. The Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the transport was not medically necessary. Our physician 
reviewer found the transportation via ambulance from the hospital upon discharge was not medically necessary.  
 The enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance 
in order to effectuate a safe transport. Transportation could have been provided by other means (stretcher van, 
wheelchair van, private car, taxi) without endangering the enrollee's condition. 
 
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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, 
non-emergency transport and ground mileage provided on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services billed with code 99153 for 
September 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 identifies technical component only stand alone codes. 
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services billed with code 99153 for September 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on July 29, 2022 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our 
physician reviewer found the transportation via ambulance from the emergency department to the enrollee's 
residence was not medically necessary. The enrollee did not require the expertise of trained personnel or the 
equipment available only on an ambulance in order to effectuate a safe transport. Transportation could have 
been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the 
enrollee's condition.  

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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, 
non-emergency transport provided on July 29, 2022
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 87500 billed for date of service August 24, 2022.

You asked the Plan to pay for procedure code 87500. You say that these services were necessary and are supported as billed. The Plan denied your request. The Plan says this service is not supported in the medical record.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 87500 is infectious agent detection by nucleic acid; vancomycin resistance (e.g., enterococcus species van A, van B), amplified probe technique.

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for procedure code 87500. Our reviewer says that this service cannot be found in the medical record. Our reviewer found that the documentation submitted does not contain results for vancomycin resistance testing, just the identification of the bacteria that was present.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 87500 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87500 billed for date of service August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wound care supplies provided on June 07, 2022, to July 06, 2022.

You asked the Plan to waive the coinsurance for wound care supplies. You say that you should not have to pay this bill because you did not receive the supplies. 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 20% coinsurance for Durable medical equipment (DME) and related supplies.

You have been asked to pay 20% coinsurance for wound care supplies. This item/service falls within the Durable medical equipment (DME) and related 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 coinsurance for wound care supplies provided on June 07, 2022, to July 06, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer.

You asked the Plan to pre-approve these services. You say that the enrollee has iron deficiency anemia. He has not tried and failed the Plan's required drug, Venofer. The records do not show that the required drug would be contraindicated or less effective; therefore, Injectafer is not reasonable or medically necessary. The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the services are 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-One injection.

You asked the Plan to pre-approve a Gel-One injection. 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 a Gel-One injection. Our reviewer says that a Gel-One injection is not medically reasonable and necessary in this case. Our physician reviewer found that there is no indication that the enrollee has tried and failed the required drug(s). 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. The provider argues that Gel-One is preferred as it only requires one injection.

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 Gel-One injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Gel-One injection.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of testicular implant (54660).

You asked the Plan to pre-approve the implant. You say that this is not a cosmetic issue it is more of a mental health issue. The Plan denied your request. The Plan says the prosthesis is for cosmetic reasons only and does not serve a medical purpose.

The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.

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 implant. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our reviewer found the enrollee with left orchialgia, status post varicocele repair in 2021, with plans for a left radical
orchiectomy. Insertion of testicular implant (54660) was also requested to be performed at the same time. However, it was not clear that insertion of a testicular implant would be medically necessary as opposed to simply cosmetic. The provided notes failed to describe the reasoning for why this procedure might be medically necessary and not cosmetic. Therefore, it will be considered 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 implant have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of testicular implant (54660).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a segmental gradient pressure pneumatic appliance, half leg (E0673) provided on July 12, 2022.

You asked the Plan to pay for a pneumatic compression device and appliance. You say that you disagree with the denial and have submitted medical records for review. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare when the place of service is an ambulatory surgical center.

The Plan follows Medicare rules. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. The records also show that the claim was billed with place of service 24, which is an ambulatory surgical center. Medicare rules say that for DME to be covered, it must be appropriate and be needed for use inside the home. The PCD was billed for use outside of the home, and it is not separately payable. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a segmental gradient pressure pneumatic appliance, half leg (E0673) provided on July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on May 23, 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 in addition to the enrollee not meeting the coverage criteria for this testing, there were also billing errors on the claim. 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 exception to the General Rule 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. 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 must be the date the specimen was collected. There is no documentation of molecular pathology testing performed on the date billed of May 23, 2022.
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 the diagnosis code to qualify for this testing reported. 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 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. Whether or not an IRF setting could be beneficial is not of issue. Enrollees must be able to participate in this type of setting. Based on the medical records provided, it was clear the enrollee would not have been capable to participate in or benefit from a rehabilitative program to include treatment 3 hours a day for 5 days a week. Medicare coverage criteria were not met.
Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 3, 2022.
You asked the Plan to pay for procedure code 70450. You say that the reports support the level of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. Maximus overturned the Plan's denial based on missing information. The Plan requested a reopening and provided records to confirm procedure code 70496 was performed on this date of service.
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 70450 is a column II code to column I code 70496. 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 70450 billed for date of service May 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to provide coverage for an MRI for the enrollee.
You asked the Plan to provide coverage for an MRI. You say that at the time of the appeal an MRI was
medically necessary. The Plan denied your request. The Plan says medical necessity was not established.
Maximus overturned the Plans denial stating an MRI would be beneficial. The Plan requested a reopen and
stated that Maximus did not apply the correct coverage criteria as necessity at that point was not established.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage for a service, the information submitted by the provider must show medical necessity. We
looked at the medical records provided. There are insufficient explanations in the records to show why
conservative therapy would not have been an option prior to the MRI. The injury occurred during exercise on
July 28, 2022. The MRI was requested August 1, 2022.
At that point in time, the standard of care with or without the MRI for this type of injury would be the same
such as pain medication, rest of the area or if ultimately needed, physical therapy. There was no documentation
provided to show these treatments would not have been an option for the enrollee at that time. There was no
time for any of these options to have been tried and failed when the MRI was requested. Therefore, we decided
that the Plan does not have to provide coverage for magnetic resonance imaging (MRI) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis services provided to the enrollee October 1, 2020, to October 3, 2020.
You asked the Plan to pay for this claim. You say that these services were medically necessary. 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 date that was submitted for the occurrence code "51" is not the date of the last reading taken during the billing period or the date span was billed as October 1, 2020, through October 3, 2020, and the occurrence date for the occurrence code "51" was billed as October 28, 2020, which does not fall into the "billing period".
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 a discrepancy with codes submitted and the dates submitted. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for dialysis services provided to the enrollee October 1, 2020, to October 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for measurement of post-voiding residual urine and/or bladder capacity by ultrasound (51798) provided to the enrollee on November 26, 2021.
You asked the Plan to pay for these services as billed. 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 stated that Maximus did not apply the correct billing criteria. The Plan noted that code 51798 was billed with Place of Service (POS) code of 23 for Emergency Room-Hospital. Per the 2021 National Physician Fee Schedule, code 51978 has a PC/TC indicator of 3. Per Medicare Claim Processing Manual Chapter 23, Section 50.6, for PC/TC Indicator 3, this indicator identifies stand-alone codes that describe the technical component (i.e., staff and equipment costs) of selected diagnostic tests for which there is an associated code that describes the professional component of the diagnostic tests only. Per the Medicare guidelines, code 51798 has a professional/technical indicator of 3. This means that code 51798 is a technical only code, and the technical component of diagnostic services are paid to the facility. An individual physician may not bill for a technical only code.
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 errors with the reported code 51798 having a billing indicator of 3, not allowing it to be separately billed. Medicare rules for coverage of these services as billed have not been met. Therefore, we decided that the Plan does not have to pay for measurement of post-voiding residual urine and/or bladder capacity by ultrasound (51798) provided to the enrollee on November 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided to the enrollee on April 19, 2021
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and demonstrated that error code 50 applied to code V2787 because this code is a non-covered "statutory exclusion" as evidenced by the status indicator "E1". Code 66894 denied correctly as 0992 or the message of "Please correct OCE edit error on other claim line" due to the error code 50 having a "Claim Return to Provider (RTP) disposition." Per Medicare guidance, as denial was applied correctly to the claim of "OCE 50" the guideline states this OCE has a return to provider (RTP) disposition. There are one or more edits present that cause the whole claim to be returned to the provider. A claim returned to the provider means that the provider can resubmit the claim once the problems are corrected.
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 due to several error codes directing the submission be returned to the provider. Medicare rules for coverage of these codes have not been met. Therefore, we decided that the Plan does not have to pay for outpatient services provided to the enrollee on April 19, 2021.