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

We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) testing provided to the
enrollee on December 2, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and provided additional information.
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 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 October 27, 2021. There is no documentation of molecular pathology testing performed on the
date billed of February 2, 2022.
In addition, the claim did not include all the documentation to process the claim. The required DEX Z Code
was not provided. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx)
testing provided to the enrollee on December 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (G0483) provided on June 23, 
2022. 
 You asked the Plan to pay for definitive drug testing. You say that this test was medically necessary and was 
ordered by the enrollee's treating physician. The Plan denied your request. The Plan says there is insufficient 
information in the medical records to show this test was medically necessary. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of definitive drug testing have been met. 
Specifically, no documentation was provided to show that a presumptive drug test was provided that was either 
presumptively positive or had inconsistent negative findings. The record does not indicate that the other 
coverage criteria of relevant policy are met and there was no presumptive test available. Without this 
documentation, there is not enough information to find these services medically necessary. Therefore, we 
decided that the Plan does not have to pay for definitive urine drug testing (G0483) provided on June 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 a HFCWOD. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive 
pulmonary disease (COPD). Bronchiectasis is listed as a diagnosis but the computed tomography (CT) scan of 
the chest report from January 11, 2022 describes "mild diffuse bronchial wall thickening." This is not the same as bronchiectasis and is consistent with chronic bronchitis. The enrollee does not have bronchiectasis, cystic 
fibrosis, or neuromuscular disease. Medicare does not cover HFCWOD in the treatment of COPD. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 15, 2022, to 
July 14, 2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the services are not payable as billed. 
 
 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
Review of the file shows that the admit date on the final claim must match the admit date on the NOA. As the 
NOA does not match the actual admit date, no payment can be made on this claim. Therefore, we decided that 
the Plan does not have to pay for the home health services provided from June 15, 2022, to July 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 19, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code 
 
We find that payment for CPT code 88360 is not supported in the medical record. Specifically, this code is 
assigned a PC/TC indicator of 1. As such, when billed with a facility place of service, modifier -26 must be 
used for payment to be considered. Based on this information, we decided that Medicare rules for coverage of 
the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on January 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this IRF admission is medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has had a functional decline from her baseline level of function and 
would likely benefit from physical and occupational therapies, but she does not require the intensity of therapies provided on acute inpatient rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint fusion. 
 
You asked the Plan to pre-approve sacroiliac joint fusion. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 sacroiliac joint fusion. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested sacroiliac joint fusion, in 
this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac joint fusion.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a pneumatic compression device and sleeves. 
 
You asked the Plan to pre-approve a pneumatic compression device and sleeves. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a pneumatic compression device (PCD) coded as 
E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen when 
specific criteria are met. 
 
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 a pneumatic compression device and 
sleeves. Our reviewer says that the services are medically necessary. Our physician reviewer found you have 
chest wall and arm lymphedema and have not responded to conservative measures including non-segmented 
compression. 
 
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 pneumatic compression device and sleeves have been met. Therefore, we 
decided that the Plan has to pre-approve a pneumatic compression device and sleeves.  
 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 services coded 72100 and 96372 provided on July 21, 
2022. 
 
You asked the Plan to pay for the services coded 72100 and 96372. 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. 
 We find that CPT codes 72100 and 96372 are not supported in the medical record. Specifically, codes 72100 
and 96372 have a status indicator of Q1. Code 99284 was billed on the same date of service with a revenue 
code 450, which has a status indicator of "V". This means that codes 72100 and 96372 are not separately 
payable. Based on this information, we decided that Medicare rules for coverage of the services coded 72100 
and 96372 have not been met. Therefore, we decided that the Plan does not have to pay for the services coded 
72100 and 96372 provided on July 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) coded E0651. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an E0651 PCD is covered when specific criteria 
are met. 
 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not adequately document 
trial and failure of conservative therapy for the lymphedema with detailed measurements, obtained in the same 
manner and with reference to the same anatomic landmarks, prior to and at the conclusion of the various trials 
and therapy, with bilateral comparisons where appropriate. The criteria for coverage are not met and the 
services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a pneumatic compression device (PCD) coded E0651.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on June 23, 2021. 
 
You asked the Plan to pay for an emergency department visit. The Plan denied your request. The Plan says 
according to Medicare guidelines an original claim submission must be filed to the appropriate Medicare 
claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were 
furnished. The claim did not meet the exception criteria guidelines outlined in Medicare Claims Processing 
Manual. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for an emergency department visit was not filed until August 19, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
June 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the thoracic medial 
branches. 
 
You asked the Plan to pre-approve the RFA services. You say that the records provided support the need for 
the requested injection services. You say that the records communicate that the enrollee does have neck or back 
pain that radiates to other areas of the body. The Plan denied your request. The Plan says there is no 
documentation of initial diagnostic medial branch blocks (MBBs) and a second confirmatory set of diagnostic 
MBBs. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are covered for 
certain indications and when medically 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 RFA services. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found there is no documentation of 
initial diagnostic medial branch blocks (MBBs) and a second confirmatory set of diagnostic MBBs. 
 
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 RFA services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) of the thoracic medial branches.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for the bone marrow aspiration (20939) provided January 27, 2022.
You asked the Plan to pay for bone marrow aspiration (20939). You say that this service should be paid. The Plan denied your request. The Plan says the bone marrow aspiration (20939) cannot be paid as billed. Maximus partially overturned the Plans denial and overturned code 20939. The Plan requested a reopen and states that code 20939 was reported incorrectly on the claim. The Plan notes that code 20939 is not supported by the medical records submitted. The guidelines state that code 20939 may be reported separately only when obtained from an anatomic site other than the vertebrae on which the primary procedure is being performed. This is not substantiated by the clinical documentation submitted for review.
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 records provided do not substantiate the separately billing of code 20939. Based on this information, we decided that Medicare rules for coverage of this code have not been met. Therefore, we decided that the Plan does not have to pay for the bone marrow aspiration (20939) provided on January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0277 billed for date of service January 6, 
2022. 
 You asked the Plan to pay for procedure code E0277. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code E0277 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code E0277 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code E0277 billed for date of service January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81455) provided on February 17, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this service was considered non-covered by Medicare at the time of 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that certain codes are automatically denied as not 
medically necessary as they are unlikely to impact therapeutic decision making in the clinical management of a 
patient.  
 
We looked at the file and Medicare rules. At the time of services, code 81455 was listed under the Group 3 
Paragraph of Article A56199. This means that this service is considered automatically denied as not medically 
necessary. Based on this information, we decided that Medicare rules for coverage of laboratory services have 
not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81455) 
provided on February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 16, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on April 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to get back to 100%. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the durable medical equipment provided on 
July 1, 2022. 
 
You asked the Plan to waive the cost share for the provided services. You say that you never asked for the 
defibrillator. 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance for the provided services. This item/service falls within the 
durable medical equipment 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 cost share for the durable 
medical equipment provided on July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel of 51 or greater genes (81455) provided to the enrollee on December 12, 2021.
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that this test was medically necessary and used to help determine treatment options. The Plan denied your request.
The Plan says that genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the specimen was collected. We looked at the file and Medicare rules. The file indicates that the DOS of the panel is not the same as the date the specimen was collected. Based on this information, we decided that Medicare rules for coverage of the targeted genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel of 51 or greater genes (81455) provided to the enrollee on December 12, 2021.