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

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 11, 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 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 regarding the denial. The Plan noted that the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that the specimen was collected on September 30, 2021. There is no documentation of molecular pathology testing performed on the date billed of February 11, 2022. The claim also did not include the required unique test identifier 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. In this case, this claim could not be paid due to inconsistency with the date of service reported and the omission of the required unique test identifier code. 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 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for breast reduction provided on June 14, 2022. 
 
You asked the Plan to pay for breast reduction. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for breast reduction 
provided on June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the records attached support the services provided. The 
Plan denied your request. The Plan says services from a non-participating provider are not covered unless 
preauthorized. 
 
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 requested 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 an office visit provided on May 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on November 5, 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 records provided do not support the services billed. There is no documentation in the medical records that this testing would determine the enrollee's treatment strategy.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. Based on the medical records provided, there is insufficient information in the record to determine if Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 11, 2022. 
 
You asked the Plan to pay for home health services. You say that the hospital staff failed to request 
authorization from the Plan. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home health services 
provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0150) and radiographic images (D0210) 
provided on September 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider is listed as an in-network provider. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an oral evaluation (D0150) and radiographic images (D0210) provided on September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on December 20, 2021.
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 the records show the enrollee had Tempus Gene Panel testing billed with multiple codes, including 81479 with a -59 modifier. However, this one code was submitted on its own on a separate claim was submitted for multiple other codes. The testing was performed on the same specimen for each claim submitted which is not allowed. In addition, the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on November 30, 2021, rather than the billed date of service December 20, 2021. There is no documentation to support genetic testing with the billed date of service. Medicare billing guidelines state when a laboratory assays two or more genes in a patient in parallel, those two or more genes will be considered part of the same panel.
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 as billed due to inconsistency with the multiple claims submitted for the same specimen and the dates of service reported versus the date the specimen was taken. 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 December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 10, 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 for medical necessity. The Plan requested a reopen and notes the issue was not medical necessity but that
the claim was billed with errors. The Plan notes there is no documentation of genetic testing performed on
February 10, 2022. Medicare rules state 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. There is
no documentation to support genetic testing on the billed date of service. Also, the claim did not include
the Medicare required unique test identifier.
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 as billed due to a discrepancy with the date
of service reported and the omission of the required unique 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 10, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 14, 2022.
You asked the Plan to pay for this testing. You say that these services 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 for medical necessity. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria. The Plan stated this is an administrative determination for non-coverage and is not based on clinical
criteria for medical necessity. The claim was billed with a date of service inconsistent with the Medicare rules.
The medical records show the specimen was collected on October 19, 2021, rather than the billed date of
service January 14, 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 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 as billed due to an issue with the dates billed
versus the specimen collection date. 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 January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 28, 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 Medicare billing criteria not met.
Maximus overturned the Plans denial for insufficient information in the case file regarding the denial. The Plan requested a reopen and provided additional information. The Plan showed that there is no documentation to support genetic testing on the billed date of service of January 28, 2022. The Medicare rules state 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. If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the date pf service of the test/service must be the date the specimen was obtained from storage. This testing was billed with a date of service inconsistent with Medicare rules governing laboratory services. The clinical records show that a specimen was collected on November 30, 2021, rather than the billed date of service January 28, 2022, with no documentation of proper storage or retrieval from storage.
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 cannot be paid as billed due to a discrepancy with the billed date of service. 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 January 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on April 
22, 2022, to April 24, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you had no other choice 
than to be admitted. 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 $275 
copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $275 copayment per day for days 1-2. The total amount you are being asked to 
pay is $550 ($275 x 2 days = $550). This item/service 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 an inpatient hospital stay provided on April 22, 2022, to 
April 24, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on December 29, 2021.
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 Medicare billing criteria were not met.
Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and stated that the issue was not medical necessity but the fact that the claim was submitted with billing errors. The Plan noted that the claim was billed with a date of service inconsistent with the Medicare rules governing laboratory services. The specimen was collected on December 3, 2021, rather than the billed date of service of December 29, 2021. The Medicare rules stated 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 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 was submitted with inconsistencies in regard to the date of service. 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 December 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telephone evaluation provided on July 22, 
2022. 
 
You asked the Plan to waive the copayment for telephone evaluation. You say that you are upset you receive 
such a high copayment, you do not recall paying a copayment in the past. 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 $25 
copayment for Outpatient mental health care. 
 
You have been asked to pay a $25 copayment for telephone evaluation. This item/service falls within the 
Outpatient mental health 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 telephone 
evaluation provided on July 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on May 17, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says prior authorization was not obtained for these services to be 
provided by an out-of-network provider. 
 
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 requested 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 skilled nursing services provided on May 17, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a panoramic x-ray (D0330) provided on September 22, 2022. 
 
You asked the Plan to pay for the x-ray. You say that you were unaware of the frequency limitation for the x-
ray. The Plan denied your request. The Plan says that your benefit for the requested item or service has already 
been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for a panoramic x-ray (D0330) provided on 
September 22, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Durable medical equipment provided on 
August 29, 2022. 
 
You asked the Plan to waive the coinsurance for Durable medical equipment. You say that you never wanted 
the back brace so you shouldnt have to pay for it. 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 20% 
coinsurance for Durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for Durable medical equipment. This item/service falls within 
the Durable medical equipment (DME) 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 $231.63 which is 20% of the allowed amount 
for the back brace. Therefore, we decided that the Plan does not have to waive the coinsurance for Durable 
medical equipment provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on July 14, 2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the assisted living facility is 
responsible for obtaining authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the domiciliary or rest 
home visit provided on July 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ER visit provided on August 25, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that your provider sent you to the 
emergency room for services to be rendered instead of an imaging center, as you requested. 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 $90 
copayment for Medicare-covered emergency room visits.  
 
You have been asked to pay a $90 copayment for an ER visit. This item/service falls within the emergency 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 an ER visit provided on August 
25, 2022.  
 Your complaint about the provider sending you to an ER instead of an imaging center is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.