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

 
We decided that the Plan does not have to pay for the imaging services rendered on August 30, 2021. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that services associated with clinical trials should be 
billed with the Q0 or Q1 modifier. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the Q0 or Q1 
modifier. 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 pay for the imaging services rendered on 
August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 16, 2022, billed with 16 
individual gene codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was billed correctly and is 
medically necessary. The Plan denied your request. The Plan says this multi-gene panel was not billed in 
accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 16, 2022, billed with 16 individual gene codes.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities provided on August 27, 2021. 
 
You asked the Plan to pay for outpatient therapy. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because G0158 is a 
more appropriate code to use. 
 
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 97530 is therapeutic activities, direct patient contact, 
each 15 minutes. 
 
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 outpatient therapy. Our reviewer says that this code does not 
meet criteria for payment. Our reviewer found the documentation supports a home visit for a homebound 
patient, performed by a Certified Occupational therapy Assistant. There is a more appropriate code to report for 
service provided in a home setting. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient therapy have not been met. Therefore, we decided that the Plan does 
not have to pay for therapeutic activities provided on August 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan has to pay for the professional fees, inpatient fees, radiation therapy, scans, and 
medications provided from March 6, 2021, to August 2, 2021. 
 
You asked the Plan to pay for the professional fees, inpatient fees, radiation therapy, scans, and medications. 
You say that you had a tumor removed followed by a short hospital stay. You also say that you received 39 
sessions of radiation treatments. The Plan denied your request. The Plan says that the services received were 
not emergent/urgent and were not authorized by the Plan. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 professional fees, inpatient fees, 
radiation therapy, scans, and medications. Our reviewer says that these services were medically reasonable and 
necessary. Our physician reviewer found you were last seen September 10, 2019 by your primary care 
physician in the United States, and have not been back to the office since then. The review has determined that 
you could not have foreseen requiring the services prior to leaving your service area. Our reviewer also found 
that the care provided was medically necessary and it would not have been medically reasonable to delay the 
services until you returned to your service area or disenrolled from the Plan. 
 
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 professional fees, inpatient fees, radiation therapy, scans, and medications 
have been met. Therefore, we decided that the Plan has to pay for the professional fees, inpatient fees, radiation 
therapy, scans, and medications provided from March 6, 2021, to August 2, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the photochromatic tint (V2744), anti-reflective coating 
(V2750), U-V lens (V2755), progressive lens (V2781), and polycarbonate or equal lens (V2784) provided on 
May 16, 2022. 
 
You asked the Plan to pay for the lens enhancements. You say that you confirmed prior to the exam that the 
exam and glasses/lens benefits were pre-approved. You also say that if you had not been approved prior to the 
exam, you would not have gotten these services. The Plan denied your request. The Plan says these services are 
not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
 
 
 
 We looked at the file and the Plan's rules. The record shows the lenses you received were enhanced lenses, and 
are not covered under your vision care supplemental benefit. Based on this information, we decided that the 
Plan's rules for coverage of the lens enhancements have not been met. Therefore, we decided that the Plan does 
not have to pay for the photochromatic tint (V2744), anti-reflective coating (V2750), U-V lens (V2755), 
progressive lens (V2781), and polycarbonate or equal lens (V2784) provided on May 16, 2022.  
 
Please Note: The Plan confirmed with the provider's office that you will not be billed for the difference, and 
you do not have a balance remaining with the office.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says they can only approve four visits. 
 
 
 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 the additional visits. Our reviewer says 
that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found 
that it is not clear whether you are homebound, given your ability to attend outpatient medical appointments. 
You do not have any documented skilled nursing needs. You have paid assistance. Home health skilled nursing 
services are being requested twice daily, rather than on an intermittent basis. As such, the requested services 
are not shown to be medically necessary, reasonable or coverable. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health skilled nursing visits.
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 16, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that these services were rendered and should be 
reimbursed. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services rendered on May 7, 2022. 
 
You asked the Plan to pay for these services. You say that you were told the services would be covered. The 
Plan denied your request. The Plan says the services are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The file shows that the 
chiropractor billed procedure codes 97012 (mechanical traction therapy), and 97014 (electrical stimulation 
therapy). Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered on 
May 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dermatology services with an out-of-network (OON) 
provider. 
 You asked the Plan to pre-approve dermatology services. You say that you want to maintain continuity of care 
and consistent monitoring of your condition. The Plan denied your request. The Plan says this provider is out-
of-network with the Plan and you can be treated by an in-network dermatologist. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 dermatology services. Our reviewer 
says that you do not meet the Medicare criteria for continued care with the out-of-network dermatologist. Our 
physician reviewer found you are not currently receiving any active treatment and/or medical management that 
makes it medically necessary to continue care with an out-of-network provider. There is nothing unique about 
your condition that would require continuity of care with the requested out-of-network dermatologist. The Plan 
has in-network dermatology specialists that have the qualifications and expertise necessary to meet the 
standards of care for treatment of your condition. Your medical management and follow-up care can be safely 
transitioned to an in-network dermatologist at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of dermatology services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve dermatology services with an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the dialysis services provided from July 1, 2020, through September 7, 
2020. 
 
You asked the Plan to pay for the dialysis services as billed. You say that these services were not paid at the 
Medicare allowed rate. The Plan denied your request. The Plan says that payment was denied as there was 
missing or incorrect information on the claim. The Plan is not able to advise the provider how to bill claims, 
however. 
 
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. The Plan has not given a specific denial rationale that can be verified by 
Maximus. The claims were denied stating that an incorrect procedure code was used. There is also mention in 
the documentation in the file that there is an issue with the modifiers used or omitted. However, a full copy of 
the claim including all codes and modifiers was not included. A copy of an Explanation of Benefits or Notice 
of Denial of Payment is not sufficient as it is not possible for Maximus to determine if the information included 
is complete compared to what is on the claim. Though it is noted that the Plan cannot advise the provider how 
to bill for services, the Plan is required to advise Maximus what the claim deficiencies are in order to have a 
denial based on claim deficiencies upheld. The file does not include this. As such, we cannot confirm that the 
claim was billed incorrectly. Therefore, we decided that the Plan has to pay for the dialysis services provided 
from July 1, 2020, through September 7, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on March 28, 2022, by the 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the office staff was not 
aware authorization should be obtained prior to visit. The Plan denied your request. The Plan says services 
received out-of-network are not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the office visit (99214) provided on March 28, 2022, by the out-
of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on March 14, 2022. 
 You asked the Plan to pay for psychotherapy visit. You say that you rendered treatment in good faith that the 
service would be reimbursed. The Plan denied your request. The Plan says the documentation does not show 
that the provider attempted to consult the attending or primary care provider about the services furnished and 
document the consent or declination to consultation. 
 
The Plan must follow Medicare rules. Medicare rules say that a clinical social worker must attempt to consult 
the beneficiarys attending or primary care physician after obtaining consent to consultation.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a record of 
consultation, or attempt to consult, with the enrollees attending or primary care physician. Based on this 
information, we decided that Medicare rules for coverage of psychotherapy visit have not been met. Therefore, 
we decided that the Plan does not have to pay for a psychotherapy visit provided on March 14, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2019 billed for date of service December 6, 
2021. 
 
You asked the Plan to pay for procedure code H2019. You say that you were attempting to become a network 
provider, and miscommunications led to this claim being denied incorrectly. The Plan denied your request. The 
Plan says these services were provided out-of-network without prior authorization. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code H2019 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H2019 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code H2019 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2019 billed for date of service December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) genetic testing panel 
provided on February 15, 2022, billed with code 81455. 
 
You asked the Plan to pay for the F1Heme testing as billed. You say that this is a medically necessary test that 
should be covered. The Plan denied your request. The Plan says this code is not covered as it is not likely to 
impact decision making. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to support the 
medical necessity of Genomic Sequential Analyses panels for patients with AML, MPN, and MDS for a 
limited number of individual biomarkers. Panels which test the covered biomarkers and are described by code 81450 may be covered by Medicare.  
 
We looked at the file and Medicare rules. Review of the information in the file shows that this panel includes 
analysis of over 50 genes. The billed code 81455 is defined as targeted genomic sequencing with analysis for 
51 or more genes. Although some of these genes may be considered medically necessary based on the rules, the 
entire panel exceeds what is covered under these provisions. Therefore, we decided that the Plan does not have 
to pay for the FoundationOne Heme (F1Heme) genetic testing panel provided on February 15, 2022, billed 
with code 81455.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 home health skilled nursing visits (G0299) and 4 
physical therapy visits (G0151). 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 the visits. Our reviewer says that the 
requested visits are not medically reasonable or necessary. Our physician reviewer found that the enrollee does 
not have documented ongoing home health skilled nursing needs (i.e., IVs, complex wound care, new ostomy, 
new tube feeds). The enrollee does not have documented ongoing home health physical therapy needs. The 
enrollee is functioning at a level commensurate with a lower level of care (i.e., home exercise program, 
outpatient therapy, layperson supervision). As such, the requested services are not medically necessary or 
reasonable. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 2 home health skilled nursing visits (G0299) and 4 physical therapy visits (G0151).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 billed for date of service December 
15, 2021. 
 
You asked the Plan to pay for procedure code 64447. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 64447 is bundled into payment for code 01402. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 
 
In this case, we have confirmed that code 64447 is a column II code to column I code 01402. While code 
64447 was billed with modifier -59, the medical records provided do not show that the service billed with the -
59 modifier is a distinct procedural service. 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 64447 billed for date of 
service December 15, 2021.