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

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service June 7, 2022. 
 You asked the Plan to pay for procedure code 11721. You say that the services were provided in good faith. 
The Plan denied your request. The Plan says payment for code 11721 is bundled into payment for code 11055. 
 
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 11721 is a column II code to column I code 11055. The code at issue 
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 
11721 billed for date of service June 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service July 18, 
2022. 
 You asked the Plan to pay for procedure code 0245U. You say that you do not have direct patient contact. The 
Plan denied your request. The Plan says payment for code 0245U is bundled into payment for code 0018U. 
 
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 0245U is a column II code to column I code 0018U. The code at 
issue 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 0245U billed for date of service July 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services at issue have been billed correctly. 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 lab services provided on April 1, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 17, 2022.
You asked the Plan to pay for this testing. You say that this testing should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan 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 October 6, 2020. The specimen was received on February 8, 2022. There is no documentation of molecular pathology testing performed on the date billed: February 17, 2022. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service. There is no documentation that the sample was taken in the laboratory. The difference in date of collection and date received confirms that the was not collected directly by the laboratory. In addition, the claim was not submitted with the required unique test identifier or DEX Z Code.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim could not be paid due to errors with the dates of service reported, the POS code reported and the omission of the required test identifier. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95886), nerve conduction studies (95908), neuromuscular junction testing (95937) and EEG (95955) provided to the enrollee on January 6, 2022.
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 for a lack of medical records in the case file. The Plan requested a reopen and provided the required medical records.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for needle electromyography (95886), nerve conduction studies (95908), neuromuscular junction testing (95937) and EEG (95955). The medical records show the enrollee was a then 76-year-old woman with a diagnosis of lumbar degenerative scoliosis with severe foraminal stenosis. Epidural steroid injections offered minimal relief. Surgical intervention, with L2-L4 transforaminal lumbar interbody fusion, and T10-L4 posterior fusion with revision of instrumentation was planned. The Plan is correct in this case, the records provided do not contain sufficient documentation to support that needle electromyography (95886), nerve conduction studies (95908), neuromuscular junction testing (95937) and EEG (95955) were medically reasonable and necessary for the enrollee in this case.
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 needle electromyography (95886), nerve conduction studies (95908), neuromuscular junction testing (95937) and EEG (95955) provided to the enrollee on January 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right ulnar nerve decompression. 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not corroborate any trial and failure of physical therapy and/or 
medications. Moreover, there are no electrodiagnostic studies to support the diagnosis. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a right ulnar nerve decompression.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the X-ray provided on July 26, 2021.
You asked the Plan to waive the copay for the X-ray. You say that you should not be responsible to pay this. The Plan denied your request. The Plan says the cost sharing will be applied according to the Plan contract.
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 up to a $30 copay for each Medicare-covered X-ray. You have been asked to pay a $30 copay for the X-ray. This item/service falls within the Medicare-covered X-ray benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the X-ray provided on July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 31, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. 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 lab services provided on August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that this device is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a ventilator is not medically necessary. Our physician reviewer found records show the enrollee may 
benefit from BiPAP with average volume-assured pressure support during sleep. This has not been tried and 
shown to fail. A ventilator is not covered when used in BiPAP mode. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services billed for services provided on June 26, 2022, 
to July 25, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that there are 
missing orders for the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The records provided included a plan of care that was signed prior to the 
services being performed. Based on this information, we decided that Medicare rules for coverage have been 
met. Therefore, we decided that the Plan has to pay for the home health services billed for services provided on 
June 26, 2022, to July 25, 2022.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 9, 2022, to 
April 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 9, 2022, to April 
7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for the comprehensive oral evaluation (D0150) and root canal (D3330) provided on May 16, 2022.
You asked the Plan to provide additional reimbursement for the dental services. You say that you should be reimbursed an additional $180. You say that there were no endodontists that could tend to you in the hospital. You also say that you had no choice but to go out of network. The Plan denied your request. The Plan says you are responsible for any charged amount above the Plan's cost-sharing amount when your services are received from an out-of-network provider.
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. You have been asked to pay the difference between the out-of-network provider's charges and the Plan's payment. 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 provide additional reimbursement for the comprehensive oral evaluation (D0150) and root canal (D3330) provided on May 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the advanced imaging services performed in an outpatient hospital provided on January 31, 2022.
You asked the Plan to waive the copay for the advanced imaging services. You say that the copayment should be reduced because you were not told there would be a $225 copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for diagnostic procedures and tests in an outpatient hospital. You have been asked to pay a $100 copayment for the advanced imaging services. This item/service falls within the diagnostic procedures and tests in an outpatient hospital benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the advanced imaging services performed in an outpatient hospital provided on January 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (77387, 77525, G6002). 
 
You asked the Plan to pre-approve proton beam therapy. You say that proton beam therapy is medically 
necessary. The Plan denied your request. The Plan says there is no documentation that the enrollee needs this 
service. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is insufficient prospective, long-term clinical data available to determine 
whether or not proton beam radiation therapy for prostate cancer is superior, inferior or equivalent to external 
beam radiation therapy, IMRT, or brachytherapy with regards to safety and efficacy. Recent data shows no 
significant differences in late (years one, two, and three) patient-reported toxicity outcomes between proton 
beam therapy and IMRT. The most recent guidelines state that proton beam therapy offers no clinical 
advantage over other forms of definitive treatment. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (77387, 77525, G6002).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on October 20, 2021.
You asked the Plan to pay for these services. You say that this testing should be paid by the Plan. The Plan
denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and provided additional information. The Plan noted in addition to this
testing being statutorily excluded, the claim was billed with a place of service (POS-81) inconsistent with
Medicare rules. An independent laboratory taking a sample in its laboratory shows "81" as place of service.
There is no documentation that the specimen was taken by the laboratory directly. The difference between date
of collection (October 20, 2021) and date received (October 23, 2021) confirms that this was not taken by the
laboratory directly. Also, the test was billed without the required unique test identifier or DEX Z-code required
for this type of testing.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, this claim could
not be paid due to inconsistencies with the POS code reported, the dates of service reported and the omission of
the required test identifiers. 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 October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR testing coded as 87481, 87496, 87500, 87511, 
87529, 87532, 87640, 87653 and 87798 provided February 21, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the referring physician ordered specialized 
testing for this enrollee and forwarded the tests directly to you. The Plan denied your request. The Plan says for 
procedure codes 87487, 87500, 87511, 87529, 87532, 87640, 87653 and 87798, the request does not meet the 
Medicare rules as reasonable and necessary. For procedure code 87496, insufficient information was submitted. 
 
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 pay for the laboratory services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Urine PCR testing on February 21, 2022 was not medically reasonable and necessary. 
Urine PCR amplification techniques raise considerable concerns regarding contamination from one specimen 
to another, creating the potential for false-positive results.  The clinical interpretation of PCR results may also 
be challenging.  Amplification of organisms representing latent infection or colonization cannot be 
distinguished from active, clinically significant infections.  Additionally, PCR may amplify fragments of 
nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation.  Finally, 
specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large 
groups of patients for many of the microorganisms. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine PCR testing coded as 87481, 87496, 87500, 87511, 87529, 87532, 87640, 
87653 and 87798 provided February 21, 2022.