Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on September 2, 2019 to 
September 11, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0156 is not supported. 
 
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 G0156 is services of home health/hospice aide in home 
health or hospice settings, each 15 minutes. 
 
We find that CPT code G0156 is not supported in the medical record. Specifically, there is no documentation 
of note and time to support the billing of 140 units of this code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the home health services rendered on September 2, 2019 to September 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 15, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

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. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided June 1, 
2021 to June 6, 2021. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that you did not stay 6 days in the 
hospital. You spent 28 hours in the emergency room and you should not be charged for the night when you did 
not have a bathroom. Your experience was not acceptable and you refuse to pay this amount. The Plan denied 
your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of 
Coverage. 
 
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 $290 
each Medicare covered day for days 1-6 for each inpatient hospitalization.  
 
You have been asked to pay $1450 ($290 x 5 days) for the inpatient stay. The inpatient stay falls within the 
Inpatient hospital care 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 inpatient 
hospital stay provided June 1, 2021 to June 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography of the thorax, diagnostic (71250) rendered by the out-of-network (OON) provider on June 11, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the computed tomography of the thorax, diagnostic (71250) rendered by the out-of-network (OON) provider on June 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 25, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99053) provided to the enrollee on March 
8, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says payment for this code is always bundled into payment for other services not specified. 
 
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 99053 is "Service(s) provided between 10:00 PM and 
8:00 AM at 24-hour facility, in addition to basic service." 
 
We find that CPT code 99053 is not supported in the medical record. Specifically, this code has a status 
indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment 
for other services not specified. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 
99053) provided to the enrollee on March 8, 2021.
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 January 24, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your son 
arrived before you left but while you were in the ambulance. You also say that since you felt better and your 
vital signs were normal, you opted to have your son take you to the emergency room. The Plan denied your 
request. The Plan says you received triage services from the ambulance provider, then declined to be 
transported. The Plan also says that ambulance transportation is only covered if your health requires both 
emergency services and ambulance transportation to a hospital, unless prior approved in advance. 
 
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 January 24, 2021. 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 January 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and bitewings (D0274)
provided on June 15, 2021.

You asked the Plan to pay for a limited oral evaluation and bitewings. You say that these are made up charges.
You say that the doctor could not validate these charges to you. The Plan denied your request. The Plan says
the correct charges have been applied.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a limited oral
evaluation and bitewings when the services are medically necessary and reasonable.

We looked at the file and Medicare rules. Bitewings are covered once a year, unless a full mouth set of x-rays
(D0210) is provided within the same year. Evidence was provided that showed a complete series of x-rays
(D0210) was provided on August 20, 2020.

Evidence was also provided that showed a limited oral evaluation (D0140) was provided on March 17, 2021.
Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation and
bitewings have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral
evaluation (D0140), and bitewings (D0274) provided on June 15, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 16, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the enrollee was on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 20, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services rendered on June 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 93922 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 93922 (noninvasive bilateral extremity study, two views) 
and 93923 (noninvasive bilateral extremity study, three views). Code 93922 is a column II code with a modifier 
indicator of 1 when billed with column I code 93923.  Code 93922 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided 
that the Plan does not have to pay for the imaging services rendered on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88341) provided November 30, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.

We looked at the file and Medicare rules. The plan made multiple requests for additional documentation to
show the tests were ordered by the physician who is treating the beneficiary. Additional documentation was not
provided. 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 lab services (88341) provided
November 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0652) provided on May 17, 2021.

You asked the Plan to pay for a pneumatic compression device. You say that a representative of the durable medical equipment supplier informed you that the supplier does not file for prior authorization for the item at issue. The Plan denied your request. The Plan says rules for payment for the item at issue have not been met.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that you had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0652) provided on May 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on May 14, 2020
and billed under code 49205.

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. The
Plan requested a reopen and stated that Maximus applied incorrect billing criteria.

Our Medical Director looked at the case file and the reopen request. At issue is whether the use of CPT code
49205. The Maximus Reviewer determined that the code at issue is supported by the documentation in the
medical record. The reviewer found the operative report documents "This was resealed sharply using Bovie
electrocautery for complete cytoreduction of tumors Involving the peritoneum measuring greater than 5 cm."
The Plan argues that neither the pathology report nor the operative report documents a peritoneal, mesenteric or
retroperitoneal tumor greater than 10 cm in diameter. "Thus, code 49205 is not supported by the documentation
provided." The medical records show the enrollee was diagnosed with metastatic colon cancer to the liver.

On April 14, 2020 the enrollee underwent radical resection of ileocolic anastomosis, segmental small bowel
resection, debulking and cytoreductive surgery of the right hemidiaphragm, radical resection of segment 6 liver
mass and diaphragm, segment 8 liver capsulectomy and resection of segment 8 liver mass and diaphragm,
peritoneal stripping of right upper quadrant peritoneum, bilateral salpingo-oophorectomy, complete
omentectomy, hyperthermic intraperitoneal chemotherapy, and splenic flexure mobilization.

The Operative Report contains the following: The peritoneal structures were inspected as well as the previous
port sites and there was some military disease noted in the right upper quadrant along the peritoneum. This was
resected sharply using Bovie electrocautery for complete cytoreduction of tumors involving the peritoneum
measuring greater than 5 cm. In addition, and along the right hemidiaphragm of the liver, there were mucinous
implants along the diaphragmatic surfaces that were thickened, and upon mobilization of the diaphragm it was
evident that the tumor was full thickness. Some had been densely adherent to the liver, and this was taken down
sharply to allow for adequate removal of tumors greater than 10 cm.

Our Medical Director has concluded that the Plan is correct in this case. The Operative Report does not contain
a description of CPT / HCPCS Code 49205: excision or destruction, open, intra-abdominal tumors, cysts or
endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest
tumor greater than 10.0 cm diameter. We looked at this coder'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 pay for surgical services provided to the enrollee on May 14, 2020
and billed under code 49205.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00142, 99100) provided on September 
30, 2020. 
 
You asked the Plan to pay for anesthesia services. You say that this was billed correctly. The Plan denied your 
request. The Plan says this cannot be paid 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. The rules also 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 find that CPT codes 00142 and 99100 are not supported in the medical record. Specifically, medical 
records documenting these codes have not been submitted. Furthermore, the file shows that 00142 was 
previous billed and paid and that 99100 has a status code of B, meaning it is a bundled service and not 
separately payable. Based on this information, we decided that Medicare rules for coverage of anesthesia 
services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services 
(00142, 99100) provided on September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
December 30, 2020.

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 enrollee did not have prior authorization for out of network care. Maximus
overturned the Plans denial due to an inappropriate contract submission. The Plan requested a reopen and
submitted the correct Plan contract for review.

The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network
providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only
in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a
network provider with the Plan. The Plan 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 out of network
physician services provided to the enrollee on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for nonstandard lens, Tier 4 ultra-progressive lenses (S0581) purchased January 1, 2021.

You asked the Plan to pay for the vision services. You say that you had paid $149 with the understanding that was all you would have to pay. The last time you got a pair of glasses was 3 years ago and they were only $140 and you asked for the same type of lenses that were in those. The Plan denied your request. The Plan says high-definition lenses are not covered under the Plan benefits.
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers 1 routine eye exam every calendar year, one pair of standard eyeglass frames and 
standard plastic eyeglasses lenses per calendar year or contact lenses per calendar year. 
 
We looked at the file and the Plan's rules. High-definition lenses are not covered under the Plan benefits. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for nonstandard lens, Tier 4 ultra-progressive lenses (S0581) purchased January 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four (4) additional chiropractic manual therapies. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says this request exceeds the yearly allowed amount of 12 chiropractic visits. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. In 2021 you have nine (19) chiropractic visits and 
twelve (12) acupuncture visits. Your 2021 EOC states this benefit covers twelve (12) routine chiropractic visits 
every year Therefore, we decided that the Plan does not have to pre-approve four (4) additional chiropractic 
manual therapies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a root canal provided on February 17, 2021
You asked the Plan to pay for these dental services. You say that these dental services should be covered by the
Plan as they were referred by a Plan provider. The Plan denied your request. The Plan says the Plan says this
treatment was not rendered by a Medicare eligible provider. Maximus overturned the Plans denial.
The Plan requested a reopen and provided additional information. The Plan states it was confirmed that the
referring provider was not a plan contract provider and the rendering provider has opted out of Medicare.
The Plan is correct in this case. Medicare does not allow services from opt out providers. Medicare generally
does not cover dental services. The Plan offers a dental benefit that exceeds Medicare coverage. For that
reason, the Plan's coverage rules apply in this case. The Plan contract specifically states the enrollees must use
licensed dental providers who accept Medicare patients. The provider used has opted out of the Medicare
program. Therefore, we decided that the Plan does not have to pay for a root canal provided on February 17,
2021