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

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service August 8, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that the claim is billed correctly and payable. 
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 86077 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 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 86077 billed for date of 
service August 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab, Cisplatin, and 5-Flourouracil (J9060, 
J9271, J9190, Q5101) 
 
You asked the Plan to pre-approve Pembrolizumab, Cisplatin, and 5-Flourouracil. You say that these 
medications are 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 Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Pembrolizumab, Cisplatin, and 5-
Flourouracil. Our reviewer says that this chemotherapy combination is not medically necessary. Our physician 
reviewer found the record indicates that the enrollee has a diagnosis of stage IV laryngeal moderately 
differentiated squamous cell carcinoma, recurrent that has progressed while on therapy.  The Food and Drug 
Administration has not stated that the requested drug combination is indicated for the enrollee's condition.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pembrolizumab, Cisplatin, and 5-Flourouracil have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Pembrolizumab, Cisplatin, and 5-Flourouracil (J9060, 
J9271, J9190, Q5101)
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gastrointestinal tract imaging (91110) provided on 
August 19, 2022. 
 
You asked the Plan to pay for the gastrointestinal tract imaging. You say that you would like the medical 
records to be reviewed for medical necessity and payment. The Plan denied your request. The Plan says this 
denial is upheld because this test was performed for suspected Crohn's Disease without documentation that 
there was no evidence provided by conventional diagnostic tests such as small bowel follow-through (SBFT), 
and upper and lower endoscopy. 
 
The Plan follows Medicare rules. Medicare rules say that a wireless capsule endoscopy is indicated for 
coverage for initial diagnosis in persons with suspected Crohn's disease. 
 
 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 gastrointestinal tract imaging. Our 
reviewer says that the criteria for coverage for the gastrointestinal tract imaging have not been met. Our 
physician reviewer found the record indicates that the enrollee has non-infective gastroenteritis and suspected 
Crohn's colitis. The record does not indicate that the enrollee has suspected Crohn's disease without evidence of 
disease on conventional diagnostic tests. Our reviewer found that the elements of the coverage criteria are not 
satisfied. Our physician reviewer also found that the requested service is not recommended. 
 
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 gastrointestinal tract imaging have not been met. Therefore, we decided that 
the Plan does not have to pay for the gastrointestinal tract imaging (91110) provided on August 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided October 
30, 2021, to October 31, 2021, billed with PDPM score- KHKE1. 
 
You asked the Plan to pay for the SNF services as billed. 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 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 SNF services as billed. Our reviewer says that the 
documentation does not support the PDPM score of KHKE1 for two days. Our reviewer found the clinical 
documentation did not support SLP comorbidity of Cerebrovascular Accident (CVA), Transient Ischemic 
Attack (TIA) or Stroke coded on the MDS. Clinical documentation did not support member received a 
mechanically altered diet during the five day look back dates. Five-day MDS Z section reflects KHXE1 as a 
HIPPS modifier. Therefore, the PDPM score of KHKE1 for two days was not supported by the documentation. 
 
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 SNF services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) services provided October 30, 2021, to October 
31, 2021, billed with PDPM score- KHKE1.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the revascularization procedure of the right lower leg 
(CPT code(s): 37220, 37224, 37221, 37232). 
 
You asked the Plan to pre-approve the revascularization. You say that the services are necessary. The Plan 
denied your request. The Plan says the documentation reviewed does not support medical necessity for the 
requested procedure. 
 
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 revascularization. Our physician 
reviewer found there is no documentation that the current symptoms are lifestyle limiting and no suggestion 
that there is any sign of limb threat.  It is noted that there is a request for treatment of the right lower leg. Tibial 
intervention in the absence of limb threat carries with it a risk of doing more harm than good. 
 
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 revascularization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the revascularization procedure of the right lower leg (CPT code(s): 37220, 
37224, 37221, 37232).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (denosumab) 1MG injection (J0897). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 medication. Our physician reviewer 
found the available medical records in the case file are incomplete, and do not include a complete 
documentation regarding bone density. The documentation is insufficient to support that Prolia (denosumab) is 
reasonably expected to be safe and effective for the enrollee in this case. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia (denosumab) 1MG injection (J0897).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for critical care, first hour (code 99291) provided on June 29, 2021. 
 
You asked the Plan to pay for critical care, first hour (code 99291). The Plan denied your request. The Plan 
says that the Plan did issue payment for outpatient surgical procedure 27818 on August 9, 2021 via check 
91812762. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a rule to substantiate the denial. 
Therefore, we decided that the Plan has to pay for critical care, first hour (code 99291) provided on  
June 29, 2021.  
 
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 procedure code 99153 billed for date of service September 
18, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the rules for 
payment have not been met. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99153 is a technical component only code and not payable in this case. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99153 billed for date of service September 18, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood draw (36415), complete blood count (85025), renal 
function panel (80069), and travel allowance for medically necessary laboratory services (P9603) provided on 
August 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was not enrolled in hospice on 
this date. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member 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 August 4, 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 blood draw 
(36415), complete blood count (85025), renal function panel (80069), and travel allowance for medically 
necessary laboratory services (P9603) provided on August 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total knee arthroplasty (CPT code 27447). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been 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 the service. Our physician reviewer 
found the medical records provided do not meet the requirements listed in the LCD for Medicare coverage for a 
right total knee. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the total knee arthroplasty (CPT code 27447).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient observation provided on July 20, 2021.
You asked the Plan to waive the copay for the outpatient observation. You say that you want to appeal the amount being charged. 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 $225 copay per Outpatient hospital observation stay. You have been asked to pay a $225 copay for the outpatient observation. This item/service falls within the Outpatient hospital observation 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 outpatient observation provided on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on March 14, 2022. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are 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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation only 
supports 12 drug classes were tested. This means that 22 or more drug classes were not testing and code G0483 
is not supported. Based on this information, we decided that Medicare rules for coverage of the drug testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 
provided on March 14, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an established patient office or other outpatient visit, 20-29 minutes 
(code 99213) provided on November 18, 2021. 
 
You asked the Plan to pay for the established patient office or other outpatient visit, 20-29 minutes (code 
99213). You say that this service was billed correctly with code 99213 and you do not understand why the level 
of service was changed by the Plan to code 99211. The Plan denied your request. The Plan says that given a 
previous review of clinical records from your practice finding significant issues with incorrect E & M service 
billing, as well as a review of the submitted diagnosis codes for this claim, we will not recognize the level of 
services billed in this case and will only pay for the E & M level usually associated with the billed diagnosis 
code(s). 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a rule to substantiate their denial of code 
99213. Therefore, we decided that the Plan has to pay for an established patient office or other outpatient visit, 
20-29 minutes (code 99213) provided on November 18, 2021.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 11, 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 for medical necessity. The Plan requested a reopen and stated the issue was not medical necessity but the fact that the claim was submitted with several errors. The Plan notes that in addition the FANCC gene test being statutorily excluded service, the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on March 28, 2022, rather than the billed date of service April 11, 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 claim did not include the required unique test identifier code or DEX Z-Code. Finally, 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 however 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 code. In this case, this claim cannot be paid as billed due to errors with the dates of service reported, the POS code reported, the omission of the required unique test identifier and the issues regarding statutory exclusion. 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 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 2, 2022, billed with 
multiple codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services at issue have been billed 
correctly. 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 2, 2022, billed with multiple codes.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 9, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 is a column II code to column I code 70496. 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 
70450 billed for date of service October 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 14, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says an incorrect place 
of service was billed. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. 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 March 14, 2022.