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

 
We decided that the Plan does not have to pay for procedure code 76882 billed for date of service June 13, 
2022. 
 
You asked the Plan to pay for procedure code 76882. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 76882 is bundled into payment for code 20610. 
 
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 76882 
is a column II code to column I code 20610. 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 76882 billed for date of service June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99222 provided on 
August 9, 2022. 
 
You asked the Plan to pay for the initial hospital care services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
 We find that CPT code 99222 is not supported in the medical record. Specifically, this service was billed with a 
place of service 21 (inpatient hospital). The enrollee's claim history shows that the enrollee was in an outpatient 
hospital observation status for this date of service. This service is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of the initial hospital care services have not been met. 
Therefore, we decided that the Plan does not have to pay for the initial hospital care services coded 99222 
provided on August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64420 billed for date of service August 4, 
2020. 
 
You asked the Plan to pay for procedure code 64420. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 64420 is bundled into payment for code 32100. 
 
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 64420 
is a column II code to column I code 32100 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 64420 billed for date of service August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and panoramic x-ray 
(D0330) provided August 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that this provided is out-of-
network. The Plan denied your request. The Plan says your benefit for the requested item or service has 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 Plans 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 requested item or service was exhausted on date of service February 25, 2020. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and 
panoramic x-ray (D0330) provided August 24, 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 1, 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. The Plan requested a reopen and stated that 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 December 23, 2021. The specimen was received on February 20, 2021. There is no documentation of molecular pathology testing performed on the date billed: March 1, 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. The sample was collected during an inpatient hospital surgical procedure. 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 did not include 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 codes. In this case, this claim could not be paid as billed due to issues with the dates of service reported, the POS code reported and the omission of required test identifier codes. 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 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 June 9, 2021.
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 noted that this is an administrative determination for noncoverage and is not based on clinical criteria for medical necessity. The Plan states the claim did not include the required unique test identifier and there is no documentation of recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer.
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 is not supported by the medical records provided nor does the claim submitted have 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 June 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 14, 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 Medicare billing criteria were not met. Maximus overturned the Plans
denial as having been ordered by a Plan provider. The Plan requested a reopen and stated the issue was billing
errors on the claim would not be affected by the status of the ordering provider. The Plan states that the claim
was billed with a dated of service inconsistent with Medicare guidelines. The records show the specimen was
collected on January 13, 2022, rather than the billed dated of February 14, 2022. The claim also 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 inconsistencies with the date of service reported 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 February 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient physical therapy services provided from February 10, 2022, to March 4, 2022.
You asked the Plan to waive the coinsurance for the physical therapy services. You say that you qualify for a dual enrollment policy that has zero cost-sharing. The Plan denied your request. The Plan says that this has processed towards your Medicaid benefits.
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services). These services qualified under the Medicaid coverage. The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to waive the coinsurance for the outpatient physical therapy services provided from February 10, 2022, to 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 April 7, 2022.
You asked the Plan to pay for this testing. 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. The Plan requested a reopen and 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 "ADLT" collected from a hospital outpatient during an encounter. However, there are several errors on the claim submitted. 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 billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that specimens were collected on February 22, 2022. There is no documentation of molecular pathology testing performed on a specimen collected by the laboratory billable with the date pf service of April 7, 2022, and POS 81. The claim form contradicts the reasoning used by Maximus to overturn the denial. The laboratory billed POS as 81, rather than 22 for "On Campus Outpatient Hospital". Medicare rules state if an independent lab bills, the place where the sample was taken is shown. An independent laboratory taking a sample in its laboratory shows "81" as place of service. If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it uses the code for the inpatient (POS code 21), off campus-outpatient hospital (POS code 19), or on campus outpatient hospital (POS code 22), which was not done 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 issues with the dates of service reported, the dates for specimen collection and 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 genetic testing provided to the enrollee on April 7, 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 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 stating the specimen was taken during an outpatient hospital encounter and provided after discharge. It is medically appropriate to collect this in the hospital setting is as it was lung tissue. The Plan requested a reopen and provided additional information. The Plan notes this claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. Medicare rules state that if an independent laboratory takes the sample in the lab, the POS code billed is "81" as place of service. However, as the records show and as Maximus states, there specimen was collected during a hospital outpatient encounter. The specimen was not taken by the independent lab as indicated by the POS code 81. The POS code on the claim should have been the code for the facility and not POS 81.
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 issues with the POS code billed. 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 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the biopsy services provided on February 19, 2022.
You asked the Plan to pay for the biopsy services. You say that this service should be paid under your medical benefit. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. However, such denials may be appealed. We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were reimbursed by the Plan on May 5, 2022. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the biopsy services have not been met. Therefore, we decided that the Plan does not have to pay for the biopsy services provided on February 19, 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 20, 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 insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan noted this 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 December 29, 2021. There is no documentation of molecular pathology testing performed on the date billed of January 20, 2022. The Plan states the required unique test identifier or DEX Z-Code was not included. The place of service (POS) code billed was 81, for Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory billed "81" as the place of service. However, the sample was collected by the physician or facility. There is no documentation that the sample was taken by the laboratory directly. 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.
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 issues with the dates of service reported, the POS code 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 January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion, normal saline solution, 250 cc (J7050) provided to the enrollee on February 17, 2022.
You asked the Plan to pay for the infusion. You say that this should be paid for. The Plan denied your request. The Plan says that fluids used to administer a drug are considered incidental hydration and are 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 CPT code. In this case, the CPT Code Manual definition of code J7050 is "Infusion, normal saline solution, 250 cc."
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 the infusion. Our coding reviewer found that the documentation is not clear on if this procedure is being reported for hydration, which would be inclusive to drug administration. Therefore, this procedure code cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the infusion have not been met. Therefore, we decided that the Plan does not have to pay for the infusion, normal saline solution, 250 cc (J7050) provided to the enrollee on February 17, 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 1, 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 for medical necessity. 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 February 1, 2022, rather than the billed date of service of March 1, 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. The Plan also notes the claim did not include the unique test identifier or DEX Z-Code. The Plan further notes 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 records show 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 codes. In this case, this claim could not be paid as billed due to issues with the dates of service reported, the POS code reported and the omission of the required test identifier codes. 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 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 April 15, 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 clarification. The Plan notes that This is an
administrative determination for billing and is not based on clinical criteria for medical necessity. 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 specimen was collected during a hospital outpatient encounter, which would not be POS code
81.
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 an incorrect POS 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 April 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 17, 2022, billed with 
codes 81170, 81191, 81192, 81193, 81235, 81272, 81276, 81309, 81314, 81401, 81403, and 81404. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
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 
June 17, 2022, billed with codes 81170, 81191, 81192, 81193, 81235, 81272, 81276, 81309, 81314, 81401, 
81403, and 81404.