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

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 6, 2022.
You asked the Plan to pay for this testing. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the records provided do not show this testing would contribute to treatment or change the outcome of the enrollee's condition. The Plan further stated the Medicare billing criteria for this testing were not met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. The rules also state 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. The records provided show the date of the specimen collection was November 3, 2020. The date of service reported for the testing was April 6, 2022. The Medicare criteria 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 April 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you were told the provider was in-network, and you 
made sure you called the Plan to verify. The Plan denied your request. The Plan says you must choose a 
primary care provider who is in-network. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 an office visit provided on July 1, 2022, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on September 14, 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 Medicare billing criteria were not met.
Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan notes that this claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records show specimens were collected on August 11, 2021, and August 26, 2021, rather than the billed date of service September 14, 2021. There is no documentation to support genetic testing with the billed date of service. The enrollee had Tempus gene panel testing billed with multiple codes, including 81479 with a -59 modifier. This one code was submitted on its own on a separate claim form; the other codes were submitted on multiple different claim forms, but testing was performed on the same specimens. Medicare billing criteria were not met
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. The rules say 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. In this case this claim cannot be paid due to inconsistent dates of service billed versus the date the specimen was taken. In addition, there were billing errors created with the codes billed for these services. 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 September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 19, 2022. 
 
You asked the Plan to pay for office visit. You say that you should not have to pay for this appointment. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
April 19, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on December 1, 2021.
You asked the Plan to pay for these services. You say that this testing was necessary due to the enrollee's risk factors. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus upheld the Plans denial based on out of network contract rules. Maximus then reopened the case and reviewed the case for medical necessity.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.
This testing was requested solely for screening purposes. There is no indication this testing would determine treatment for current or active disease in the enrollee. This test was stated to have been ordered due to the enrollee's possible "risk factors". Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for onabotulinumtoxina injection provided on June 16, 2022. 
 
You asked the Plan to pay for onabotulinumtoxina injection. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for onabotulinumtoxina 
injection provided on June 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing services provided on June 5, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for genetic testing services. You say that the primary care provider provided the 
specimens. The Plan denied your request. The Plan says authorization was not obtained prior to services 
rendered, and the referring provider was out of network. 
 
 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 genetic testing services provided on June 5, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the original denial was incorrect, and that the provider 
is in-network. The Plan denied your request. The Plan says services from non-participating providers are not 
covered unless preauthorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 an office visit provided on April 5, 2022, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on September 26, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you would 
like this denial to be reversed. The Plan denied your request. The Plan says this service is not covered by 
Medicare or your benefit plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 26, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the reports attached support the services provided. The 
Plan denied your request. The Plan says services from a non-participating provider are not covered unless 
preauthorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 an office visit provided on May 24, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission provided on May 22, 2022. 
 
You asked the Plan to pay for inpatient admission. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for inpatient admission 
provided on May 22, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 12, 2022.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and stated that the issue was not medical necessity but the fact that the claim was submitted with technical billing errors. The Plan demonstrated that the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that a specimen was collected on November 24, 2021. There is no documentation of molecular pathology testing performed on the date billed of January 12, 2022. Also, the claim did not include the required unique test identifier code. Medicare rules state 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 and the appropriate unique test identifier must be reported adjacent to the current procedure terminology 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 an issue with the date of service reported and the omission of the required unique testing 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 January 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital service provided on 
April 01, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital service. You say that you are being billed 
more than you should be. 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 $250 
copayment for Outpatient hospital services. 
 
You have been asked to pay a $250 copayment for outpatient hospital service. This item/service falls within the 
Outpatient hospital 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 outpatient 
hospital service provided on April 01, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on June 27, 
2022. 
 
You asked the Plan to waive the copayment for a cystourethroscopy. You say that this procedure was an 
extension of a previous procedure that did not work. 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 $250 
copayment for outpatient surgery. 
 
You have been asked to pay a $250 copayment for a cystourethroscopy. This item/service falls within the 
outpatient surgery 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 a cystourethroscopy 
provided on June 27, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on December 10, 2021.
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. The Plan requested a reopen and provided additional information. The Plan demonstrated that the enrollee had Tempus Gene Panel testing billed with multiple codes, including 81479 with a -59 modifier. This one code was submitted on its own on a separate claim form; the other codes were submitted on a different claim form, but testing was performed on the same specimen. Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. Additionally, modifiers should not be used to report multiple codes when a single specimen is tested. This testing was done on a single blood/tissue specimen. Finally, the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimens were collected on November 10 and 23, 2021, rather than the billed date of service December 10, 2021.
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 dates of service billed and the multiple claims submitted for testing on the same specimen. 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 December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening lab work provided on August 09, 2022. 
 
You asked the Plan to pay for screening lab work. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for screening lab work 
provided on August 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on July 14, 2022. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you shouldnt have to pay for 
this. 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 $40 
copayment for Urgently Needed Services. 
 
You have been asked to pay a $40 copayment for urgent care visit. This item/service falls within the Urgently 
Needed 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 urgent care visit 
provided on July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 03, 2022. 
 
You asked the Plan to pay for an office visit. You say that you were told by the provider that they were in-
network. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 03, 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 4, 2022.
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 were not met.
Maximus overturned the Plans denial stating the testing was medically necessary. The Plan requested a reopen and stated the issue was not medical necessity but the fact that there were billing errors on the claim itself. The Plan noted that the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that a specimen was collected on September 30, 2021. There is no documentation of molecular pathology testing performed on the date billed of February 4, 2022. The claim also did not include the required test identifier code. Medicare billing guidelines state 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.
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 dates of service reported and the omission of the required 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 4, 2022.