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

We decided the Plan does not have to pay for genetic testing provided to the enrollee on June 23, 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 stated that Maximus did not apply the correct criteria. The Plan notes that 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 with 3 exceptions. Maximus references the exceptions regarding a specimen collected from a hospital outpatient during an encounter. However, 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 claim was also billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that specimens were collected on June 4, 2021. There is no documentation of molecular pathology testing performed on a specimen collected during an outpatient encounter properly billed with the date of service of June 23, 2021, and POS 81. The claim form contradicts the reasoning used by Maximus to overturn the denial. The laboratory billed POS as 81, rather than POS code 22 for outpatient hospital.
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 due to issues with the POS code reported and discrepancies with the dates of service billed. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for to pay for genetic testing provided to the enrollee on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone replacement graft - retained natural tooth (D4263).
You asked the Plan to pre-approve these services. You say that without the bone replacement graft your dental work cannot be completed. The Plan denied your request. The Plan says that the service being requested is not a covered benefit under your dental plan.
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 bone replacement graft - retained natural tooth (D4263).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller (E2377), expandable controller harness (E2313) and a power seat elevation feature (E2300) for the enrollee.
You asked the Plan to pre-approve an electronic connection (E2311), expandable controller (E2377), expandable controller harness (E2313) and a power seat elevation feature. You say that these items are medically necessary. The Plan denied your request. The Plan says that the enrollee is able to control the power options using their own switches.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules also say that a power seat elevation feature is non-covered because it is not primarily medical in nature. Our Medical director looked at the case file and the reopen request. At issue is coverage for an electronic connection, expandable controller and an expandable controller harness. Our Medical Director states that the documentation supports that the enrollee's upper limb strength and function were adequate to control power options through their own switches. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller (E2377), expandable controller harness (E2313) and a power seat elevation feature (E2300) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on November 17, 2021.
You asked the Plan to pay for the gingival irrigation. You say that you would like the Plan to pay for this. The
Plan denied your request. The Plan says that the rendered dental service is not a covered benefit.
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 pay for the
gingival irrigation (D4921) provided on November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 15, 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 stated that Maximus did not apply the correct criteria. The Plan notes the claim was billed with a date of service inconsistent with Medicare rules. The records submitted show that specimens were collected on January 3, 2022. The specimen was received on February 6, 2022. There is no documentation of molecular pathology testing performed on the date billed of February 15, 2022. The claim was also 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. There is no documentation that the sample was taken in the laboratory. The difference in date of collection and date received confirms that the was not collected directly by the laboratory. Finally, the claim did not include the required unique test identifier or DEX Z-Code.
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 due to issues with the POS code, the dates of service reported and the omission of the required test identifier 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 February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 15, 2022.
You asked the Plan to pay for these services. You say that this testing 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 medical necessity. The Plan requested a reopen and stated Maximus did not apply the correct criteria. The Plan notes that the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that specimens were collected on July 13, 2021. The specimen was received on February 6, 2022. There is no documentation of molecular pathology testing performed on the date billed: February 15, 2022. In addition, 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. There is no documentation that the sample was taken in the laboratory. The difference in date of collection and date received confirms that the was not collected directly by the laboratory. Also, the claim was not billed with the required unique test identifier or DEX Z-Code.
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 errors cited with the POS code billed, the dates of service billed and the omission of a required test identifier 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 February 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for surgery services provided on April 18, 2022 under code 49650.
You asked the Plan to pay for these services. You say that these services 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 stated Maximus did not apply the correct billing guidelines. The Plan notes the requested code is an NCCI Procedure to Procedure edit with another code based on the Procedure-to-Procedure rationale of "Standards of medical/surgical practice. It is inappropriate to separately report services that are integral to another procedure with that procedure. As a result, the requested procedure code has a CCI conflict with code 44120 and would be considered inclusive to code 44120. No acceptable Modifier has been approved. Therefore, the requested code 49560-59 cannot be paid as billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case code 49560 cannot be paid as billed due to its relationship with code 44120 also billed on the claim. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for surgery services provided on April 18, 2022 and billed under code 49650.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing (81479) provided to the enrollee on March 4, 2022.
You asked the Plan to pay for the genetic testing. You say that these services were necessary and are supported in the medical records. The Plan denied your request. The Plan says that this claim was billed with an incorrect place of service. Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was collected in the hospital. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing (81479) provided to the enrollee on March 4, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 9, 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 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 notes that the claim was billed with a POS code of 81, which would indicate the independent lab took the specimen. However, the medical records show the specimen was taken at an outpatient hospital, which would not be POS code 81. In addition, the Plan states that panels that include the "FANCC" gene are statutorily excluded.
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, we find this claim was not billed with an appropriate POS code. Even if the testing could be covered, due to inappropriate billing, 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 March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 12, 2022.
You asked the Plan to pay for this testing. You say that this testing should be covered by the Plan. The Plan
denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and stated Maximus did not apply the correct billing criteria. The Plan
notes that the claim was billed with a POS code of 81, however there is no documentation that the independent
lab actually took the specimen. As the specimen was take in an outpatient hospital setting the POS code should
have been billed as 22. In addition, the records show the specimen was collected on June 4, 2021. There is not
documentation of any testing done on the date billed by the lab which was April 12, 2022.
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 errors with the POS code billed and the reported dates of service. Medicare
rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay
for genetic testing provided to the enrollee on April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 10, 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 stated that Maximus did not apply the correct billing guidelines. The Plan notes that the claim and the lab report do not name the same enrollee. The claim was billed with a POS code of 81, but there is no indication the independent lab took the specimen. There is also a discrepancy between the dates the specimen was taken, and the dates billed by the lab.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Data elements on the claim inconsistent with the medical records will results in denial of payment. In this case, this claim showed errors with the enrollee identified, the POS code and the dates of service 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 February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve guided tissue regeneration on tooth #4, 5, and 6 (D4266), endosteal implant on tooth #4 and 6 (D6010), custom fabricated abutment on tooth #4 (D6057), implant supported crown on tooth #4 (D6065), and a bone graft on tooth #4 (D6104) for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the requested 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 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 guided tissue regeneration on tooth #4, 5, and 6 (D4266), endosteal implant on tooth #4 and 6 (D6010), custom fabricated abutment on tooth #4 (D6057), implant supported crown on tooth #4 (D6065), and a bone graft on tooth #4 (D6104) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing provided to the
enrollee on January 21, 2021.
You asked the Plan to pay for the F1CDx testing. You say that this is an FDA-approved test that is covered by
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD)
that indicates that any panel that tests for the FANCC gene is noncovered. Maximus overturned the Plans
denial for medical necessity. The Plan requested a reopen and stated the issue was not medical necessity issue
but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81,
Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking
a sample in its laboratory shows "81" as place of service, however, the specimen was collected in the hospital.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, this claim
cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing
have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx
(F1CDx) testing provided to the enrollee on January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical X-ray
(D0220) provided to the enrollee on March 16, 2022.
You asked the Plan to pay for the dental services. You say that you feel this was an emergency. The Plan
denied your request. The Plan says your benefit for the requested services have already been exhausted.
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, certain limitations apply. The record
shows your benefit for the limited oral evaluation was exhausted on date of service February 9, 2022, and the
benefit for the periapical X-ray was exhausted on date of service November 29, 2021.
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical
X-ray (D0220) provided to the enrollee on March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on February 28, 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 stated that Maximus applied the incorrect billing criteria. The Plan
notes that the specimen was taken during an outpatient surgical procedure and not by the Independent Lab.
Therefore, the POS code billed should have been 22 and not 81, as the lab did not personally collect the
specimen. The records also show the specimen was taken on December 15, 2021, and not the billed date of
February 16, 2022.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, this claim could
not be paid as billed due to an error with the POS code reported and the dates of service codes reported.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for lab services provided to the enrollee on February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the continuous glucose monitor (CGM)
sensors provided on December 29, 2021, and January 31, 2022.
You asked the Plan to waive the cost-sharing for the continuous glucose monitor (CGM) sensors. You say that
you canceled this when your doctor took you off. 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 2021 contract with the Plan clearly says that you must pay a
20% coinsurance for Durable medical equipment (DME) and related supplies. Your 2022 contract with the
Plan says that there is a $450 deductible which applies to covered in-network medical services, including
durable medical equipment.
You have been asked to pay a 20% coinsurance for the continuous glucose monitor (CGM) sensors provided on
December 29, 2021. 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.
The CGM sensors you asked the Plan to waive the deductible for fall within the covered in-network medical
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there
is a $450 deductible which applies to the CGM sensors. This cost sharing is a contractual obligation that had
not been met at the time the CGM sensors were received on January 31, 2022.
Therefore, we decided that the Plan does not have to waive the cost-sharing for the continuous glucose monitor
(CGM) sensors provided on December 29, 2021, and January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on December
31, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says that the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the
specimen was collected.
We looked at the file and Medicare rules. The file indicates that the DOS of the test is not the same as the date
the specimen was collected. Based on this information, we decided that Medicare rules for coverage of the
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the
laboratory services provided to the enrollee on December 31, 2021.