Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a prosthetic leg to include an Ossur OP4 knee
coded as L5845.
You asked the Plan to provide coverage for the component ordered as L5845. We note the Plan approved the
prosthetic and all other Medicare covered components. You say that at the time of the appeal, the requested
prosthetic and components was medically necessary. The Plan denied your request. The Plan says the order for
knee component L5845 was not valid as it is not a Medicare allowed code. Maximus overturned the Plans
denial for insufficient information regarding this denial. The Plan requested a reopen and provided additional
information. The Plan notes that while several "OSSUR" knees use code L5845, the "Ossur OP4 Knee, which
is the knee ordered by the prosthetist, is not one of them, therefore, the code requested was invalid.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
request services under the appropriate codes. In this case, the Plan has confirmed that code L5845 is not a valid
knee component code for the Ossur OP4 knee. Medicare coverage criteria were not met. Therefore, we decided
that the Plan does not have to provide coverage for a prosthetic leg to include an Ossur OP4 knee coded as
L5845.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for K3 prosthetic components (L5822, L5845, L5850, L5979).
You asked the Plan to provide coverage for K3 prosthetic components (L5822, L5845, L5850, L5979). You say that at the time of the appeal, the requested components were medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
The Plan demonstrated that medical records do not corroborate that the enrollee is a K3 ambulator. The records show the physician stated the enrollee is "expected" to be a K3 ambulator, however the actual medical record does not corroborate this. The records show the enrollee uses a walker for ambulation. This is not consistent with a K3 ambulator.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that medical records must corroborate the enrollees need for a specific type of component. Enrollees must meet the criteria for the component, not have the "potential" to become the type of ambulator the component is approved for. Medicare coverage criteria were not met at the time of the appeal. Medicare rules for coverage of the requested prosthetic components were not met. Therefore, we decided that the Plan does not have to provide coverage for K3 prosthetic components (L5822, L5845, L5850, L5979).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for genetic testing provided to the enrollee on February 10, 2022.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan notes that the reviewer incorrectly references a Local Coverage Determination (LCA) which was not referenced in the denial. The reviewer also erroneously indicated the testing was performed; however, per the claim form, services were rendered (box 32). Per the Medicare Local Coverage Article (A53628) in effect on the date of service, testing for the FANCC gene is not a Medicare benefit and is statutorily excluded service. In addition to single gene testing, panels that include the FANCC gene is statutorily excluded service. The FoundationOne CDx panel includes testing for FANCC. Further, the claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service. The medical records show the specimen was collected in the hospital.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid due to its statutory exclusion and the reporting of an incorrect POS code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for to pay for genetic testing provided to the enrollee on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 28, 2021.
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 provided additional information. The Plan notes that the claim was billed with a date of service inconsistent with Medicare billing rules. The records submitted show the specimens were collected from the enrollee on February 9, 2021. The specimens were received by the billing laboratory on September 17, 2021. The claim was billed with a POS code of 81, indicating collection by the billing laboratory, however the records clearly show the specimens were not taken by the independent laboratory. Therefore, the POS code of 81 is incorrect. In addition, the claim was submitted without the unique test identifier or DEX Z-code, which is required by Medicare.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim could not be paid due to issues with the dates of service reported, the POS code reported and the omission of a required test identifier code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on March
24, 2021.
You asked the Plan to pay for any of these services. You say that this claim should be billed. The Plan denied
your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans
denial. The Plan requested a reopen and provided additional information. The Plan notes that this claim denied
because multiple physicians or assistants at surgery may not be paid. The records show the rendering provider
is a Physician Assistant, and they are not allowed payment. The provided did not bill the claim with modifier
"AS" which should be appended to a service to indicate when assistant-at-surgery services are provided by a
non-physician such as a Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist.
The Plan is correct in this case. The Plan follows Medicare rules. The rules say that Medicare only pays for
assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery
bears the appropriate designation.
In this case, this claim could not be paid due to the omission of the required AS modifier. Medicare rules cover
full coverage of this claim were not met. Therefore, we decided that the Plan does not have to pay for surgical
assistant services provided to the enrollee on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for genetic testing provided to the enrollee on April
19, 2022.
You asked the Plan to pay for this testing.  You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan
requested a reopen and demonstrated that this was an administrative denial due to billing errors. The Plan states
the claim was billing with an inappropriate POS code of 81 and the testing done has not been cleared or
approved by the Food and Drug Administration (FDA) nor is it a companion diagnostic for any therapy.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, the claim submitted was reported with an incorrect POS code. Medicare
rules for coverage of this testing was not met. Therefore, we decided that the Plan does not have to pay for to
pay for genetic testing provided to the enrollee on April 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an advanced foot feature for a prosthesis.
You asked the Plan to provide coverage for an advanced foot feature. You say that at the time of the appeal, an advanced foot feature was medically necessary. The Plan denied your request. The Plan says the medical records do not support that you meet the criteria for an advanced foot feature. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan notes while the prosthetist notes stat you are a K3 ambulator, the physician notes do not support this statement. There is no objective clinical documentation to support that you are a K3 ambulator. The notes specifically state that you use a walker for ambulation. This is not consistent with K3 ambulation.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules state the medical records and not statements alone must confirm your ambulation ability at the time the advanced foot feature is ordered.
The medical records in this case are inconsistent and do not show you met the criteria needed at the time of the appeal for coverage of an advanced foot feature. Therefore, we decided that the Plan does not have to provide coverage for an advanced foot feature for a prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental benefits (D0150) provided on October 20, 2021.
You asked the Plan to pay for these dental services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted in 2020 and this service is only covered every three years. Maximus overturned the Plans denial for insufficient claim in the case file. The Plan requested a reopen and provided the required information.
The Plan is correct in this case. 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the record shows code D0150 was covered by the Plan on February 28, 2020. This service is only covered once every three years. Therefore, we decided that the Plan does not have to pay for dental benefits (D0150) provided on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152, 99153)
provided to the enrollee on December 8, 2021
You asked the Plan to pay for these services. You say that the Plan should pay this claim. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and provided additional information. The
Plan demonstrated that this claim did not bill correctly. Medicare coding rules indicate the codes 99152 and
99153 are found under Column Two of the edit pair, and code 77300 is found under Column One. The Column
two codes are denied as the mutually exclusive procedures cannot be performed
at the same anatomic site or same enrollee encounter.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, this claim
cannot be paid as billed due to the code edits associated with the services billed. Medicare rules for coverage of
these services were not met. Therefore, we decided that the Plan does not have to pay for moderate sedation
services (procedure code 99152, 99153) provided to the enrollee on December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a respiratory panel provided to the enrollee on November 29, 2021 and billed under code 87633.
You asked the Plan to pay for code 87633. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says while code 87798 was paid, the respiratory panel billed under 87633 was not demonstrated to be medically necessary. Maximus overturned the Plans denial stating their decision rationale was not clear. The Plan requested a reopen and provided several examples of arguments where this code is typically not covered as it provides no further diagnosis or treatment value.
The Plan is correct in this case. The Plan follows Medicare rules. The rules explicitly say that screening tests are not covered. The rules say that providers must submit medical record documentation to support the services billed. In this case there is no indication in the medical records that the results of this respiratory panel would change the course of treatment already intended for the enrollee. Medical necessity has not been established and therefore this panel is being viewed as a screening which is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for a respiratory panel provided to the enrollee on November 29, 2021 and billed under code 87633.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for four additional home health visits.
You asked the Plan to provide coverage for four additional home health visits. You say that at the time of the appeal the requested visits were medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and states that Maximus did not apply the correct criteria. The Plan noted that you had been receiving home health care visits which started in June of 2022, for over four months at the time of the appeal.
You were provided with ample time be given instruction on safety measures, an emergency plan, and fall precautions. The Medicare guidelines state skilled services are typically appropriate for a 21-day period or less. Extensions may be considered in exceptional circumstances. There is no documentation in the medical records of a change in medical condition, recent hospitalization, or specific need for continued skilled care beyond what had previously been provided.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary. Based on the medical records provided, you did not meet the criteria required for approval of additional home visits at the time of the appeal. Therefore, we decided that the Plan does not have to provide coverage for four additional home health visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on May 22, 2022.
You asked the Plan to pay for this testing. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan notes that this claim was billed with an inappropriate POS code of 81, indicating the specimen was taken by the billing laboratory. However, the medical records show the specimen was taken during an outpatient visit and sent to the billing provider. The Plan also notes the testing done is statutorily excluded.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid due to an error with the POS code and a lack of documentation to show this test was covered by Medicare. The 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 May 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for dental services coded as D5213.
You asked the Plan to provide coverage for dental services coded as D5213. You say that at the time of the appeal, these dental services were medically necessary. The Plan denied your request. The Plan says code D5213 has coverage limitations. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct coverage criteria. Documentation was provided to show the Plan paid for code D5213 on September 24, 2021. This benefit is only covered every five years.
The Plan is correct in this case. 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 covers code D5213 every five years. These services were not available for coverage at the time they were requested. Therefore, we decided the Plan does not have to provide coverage for code D5213.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 16, 2022.
You asked the Plan to pay for these services. 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 stated that, this is an administrative determination for non-coverage and is not based on clinical criteria for medical necessity. Testing for the FANCC gene is not a Medicare benefit and is statutorily excluded service. In addition to single gene testing, panels that include the FANCC gene is statutorily excluded service. The FoundationOne CDx (F1CDX) panel includes testing for FANCC. In addition, the claim did not have the unique test identifier or DEX Z-Code required for billing this type of test. Finally, the claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office meaning an independent laboratory took the sample. However medical records show the specimen was collected in the hospital.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this was a claim for statutorily excluded services that was billed without the required test identifier and with an incorrect POS code.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction services provided on February 12, 2021.
You asked the Plan to pay for eye refraction services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says eye refraction services are not covered in this setting. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language. The Plan demonstrated that this is an appeal for denial of payment for a vision eye refraction (92015) provided by February 12, 2021. The Plan does offer a supplement benefit for vision services that allows coverage for one routine eye exam per year. However, according to the medical records provided by the physician, this visit would not be considered a routine eye exam as this was to treat dry eye syndrome of bilateral lacrimal glands.
The Plan is correct in this case. Medicare generally does not cover routine vision and eyewear services. 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. While the Plan covers refraction services under certain circumstances, this type of diagnostic exam is not one in which refraction would be covered.
Therefore, we decided that the Plan does not have to pay for eye refraction services provided on February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry visits provided on September 22, 2022, to September 29, 2022.
You asked the Plan to waive the copayment for podiatry visits. You say that this should be covered. 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 $35 copayment for podiatry visits.
You have been asked to pay a $35 copayment for podiatry visits. This item/service falls within the podiatry visits 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. You have been asked to pay $70 ($35 x 2 visits) copayment for your podiatry visits. Therefore, we decided that the Plan does not have to waive the copayment for podiatry visits provided on September 22, 2022, to September 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on April 28, 2022, and May 6, 2022,
under your medical benefit instead of the dental benefit.
You asked the Plan to pay for these services under your medical benefit. You say that you would like these
services covered under your medical benefits and not covered as dental benefits. The Plan denied your request.
The Plan says these services were coded as dental procedures by the provider, and they were rendered by a
dentist. The Plan states these services do not qualify for coverage under your medical benefit. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
coverage criteria.
The Plan is correct in this case. Medicare 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.
These services were clearly provided by a dentist and coded as dental services. These services are not covered
under your medical benefit. Therefore, we decided that the Plan does not have to pay for dental services
provided on April 28, 2022, and May 6, 2022, under your medical benefit instead of the dental benefit.