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

 
We decided that the Plan does not have to pre-approve bone and/or joint imaging; whole body (78306). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not necessary. 
 
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 service. Our physician reviewer 
found the medical records provided do not meet the requirements listed in the NCD for Medicare for coverage 
of single photon emission computed tomography (SPECT) imaging. The records do not show that you have a confirmed diagnosis of a specific type of cancer as required.  
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone and/or joint imaging; whole body (78306).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 2, 2022, to 
March 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not have the first date in 2022 as required. Based on this information, we find that the Medicare rules for 
payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from March 2, 2022, to March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11042 billed for date of service 
May 18, 2022. 
 
You asked the Plan to pay for procedure code 11042. You say that you neglected to append a modifier to the 
claim. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 15275 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 11042 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 11042 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 11042 billed for date of service May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 foot for the enrollee.
You asked the Plan to pre-approve a K3 foot. You say that the item is necessary. The Plan denied your request. The Plan says that the K3 foot exceeds the enrollee's needs.
Our Medical director looked at the case file and the reopen request. At issue is coverage for a K3 foot. Our Medical Director states that there is insufficient documentation to support that the enrollee was a K3 ambulator at the time of the review, and there is insufficient clinical documentation of functional need for the technologic or design feature of the advanced foot and advanced knee. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of a K3 foot.
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 K3 foot have not been met. Therefore, we decided that the Plan does not have to pre-approve a K3 foot for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the arthrocentesis provided on March 10, 2022.
You asked the Plan to waive the copay for the arthrocentesis. You say that you previously received the same procedure with the same provider and was only charged a $50 copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copay for each Medicare-covered outpatient hospital facility visit. You have been asked to pay a $275 copay for the arthrocentesis. This item/service falls within the Medicare-covered outpatient hospital facility visit 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 copay for the arthrocentesis provided on March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on December 3, 2021.
You asked the Plan to pay for these services. You say that this testing should be paid by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan notes the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on November 9, 2021, rather than the billed date of service of December 3, 2021. 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. In addition, the claim was not billed with the required unique test identifier or DEX Z-Code.
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 due to the omission of the required test identifier and inconsistency with the dates of service billed. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on December 3, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for home health services for the enrollee.
You asked the Plan to provide coverage for home health services. You say that at the time of the appeal, home
health services were medically necessary. The Plan denied your request. The Plan says the services were not
medically necessary. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct Medicare criteria. The Plan notes that the medical records do not document
a need for on-going or new sessions of home skilled therapy or skilled nursing services.
The enrollee had already been educated on a home exercise program. There is no documentation of an active or
acute on-going chronic condition that would necessitate a new program.
The Plan is correct in this case. 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. Based on the medical records provided, the enrollee
did not meet the Medicare criteria for home health services at the time of the appeal. Therefore, we decided that
the Plan does not have to provide coverage for home health services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 1, 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 provided additional information. The Plan noted 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. In addition, the claim was not submitted 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 code. In this case, this claim could not be paid due to errors with the POS code and the omission of the required test identifier code. Medicare rules for coverage of this testing were not met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 2, 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 Plan states the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan notes that the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on January 17, 2022, rather than the billed date of service February 2, 2022. 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. In addition, the claim was not submitted with a unique test identifier or DEX Z-Code required by Medicare.
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 was submitted with inconsistent dates of service and did not include the required unique 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 2, 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 3, 2022.
You asked the Plan to pay for this testing. 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 for medical necessity. The Plan requested a reopen and stated the issue was not medical necessity but the fact that the claim was submitted with billing errors. The Plan noted this claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on February 10, 2022, rather than the billed date of service March 3, 2022. 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. In addition, the claim was not billed with the required unique test identifier code 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, the claim was denied due to inconsistent dates of service versus specimen collection and the omission of the required test identifier code. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 3, 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 29, 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 are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that this was an administrative denial for billing issues. The Plan states 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 December 20, 2021. The specimen was received on March 19, 2022. There is no documentation of molecular pathology testing performed on the date billed of March 29, 2022. 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. Medicare Guidance Says: No payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period. 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. If an independent lab bills for services, the place where the sample was taken is shown. POS code 81 is used to describe samples taken by the laboratory directly. In addition, the claim was not submitted with the require 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 the inconsistencies with the dates of service versus the specimen collection, the POS code and the omission of the unique test identifier. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 29, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 3, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this claim is for the anesthesia used for the 
procedure and was not included on the authorization but should be covered. The Plan denied your request. The 
Plan says procedure code 99100 is considered bundled and not separately payable. 
 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 11, 
2022, to April 27, 2022. 
 
You asked the Plan to pay for SNF care. You say that you are appealing the denied payment for the SNF care. 
The Plan denied your request. The Plan says the enrollee's 100-day SNF benefit has been 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 the enrollee received 100 days of SNF care during the benefit period. The Plan covered 
SNF care during the dates of May 3, 2022, to June 19, 2022, and June 28, 2022, to July 14, 2022. The Plan also 
covered the SNF care during the dates of April 4, 2022, to April 10, 2022. The Plan has covered 100 days of 
SNF care. 
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when they 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 pay for skilled nursing facility (SNF) care provided from April 11, 2022, to April 
27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction of an erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210) for two teeth, a fixed partial denture sectioning (D9120), and 
endodontic therapy of the molar tooth (D3330). 
 You asked the Plan to pre-approve an extraction of an erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210) for two teeth, a fixed partial denture sectioning (D9120), and endodontic therapy 
of the molar tooth (D3330). You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says tooth extractions, root canals, and endodontic therapy are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 an 
extraction of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) for two teeth, a 
fixed partial denture sectioning (D9120), and endodontic therapy of the molar tooth (D3330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth # 19 and 20 (D2950) provided on 
April 28, 2022. 
 
You asked the Plan to pay for core build up. You say that a pre-treatment was completed indicating that two 
crowns would be covered at 50%. The Plan denied your request. The Plan says core build up (D2950) is not 
covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 core build 
up on tooth # 19 and 20 (D2950) provided on April 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance and emergency room 
services provided from August 12, 2022, to August 17, 2022. 
 You asked the Plan to waive the copayment for the ambulance and emergency room services. You say that you 
don't agree with the charges relating to your level of patient care. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for each one-way Medicare-covered ambulance transport. Your contract with the Plan also clearly 
says that you must pay a $90 copayment for each Medicare-covered emergency room visit.  
 
You have been asked to pay $455 for an ambulance and two emergency room visits ($275 + $90 + $90). These 
items/services fall within the ambulance and emergency care services 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 ambulance and emergency room services provided from August 
12, 2022, to August 17, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010-GP billed for date of service August 
25, 2022. 
 
You asked the Plan to pay for procedure code 97010-GP. You say that the requested services should be covered 
by the approved authorization. The Plan denied your request. The Plan says procedure code 97010-GP is 
considered bundled and not separately payable. 
 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 97010-GP has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 97010-GP is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of procedure code 97010-GP have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 97010-GP billed for date of service August 25, 2022.