Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac event monitor to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve a cardiac event monitor to be provided by the requested out-of-network 
provider. You say that the services are medically necessary. The Plan denied your request. The Plan says 
according to Medicare guidelines, an out-of-network provider may be needed if the Plan does not have a doctor 
who can do the services that are needed to treat your problem. This request can be safely given by an 
in-network provider; therefore, the requested service cannot be covered under Medicare or your health Plan. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a cardiac 
event monitor to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out of network office visits provided on 
August 24, 2022. 
 
You asked the Plan to waive the coinsurance for out of network office visits. You say that you never had to pay 
this in the past so you shouldnt have too now. 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 50% 
coinsurance for Office visits. 
 
You have been asked to pay 50% coinsurance for out of network office visits. This item/service falls within the 
Office 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 $87.76 which is 50% of the allowed amount for the out of network office 
visit. Therefore, we decided that the Plan does not have to waive the coinsurance for out of network office 
visits provided on August 24, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on August 28, 2021.
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 billing 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 noted that codes 88341-XU, 88342-XU and 88381 were denied because they were not billed with the required 26 modifier. The Plan further states code 88360 was denied because it was billed inappropriately. This code has a bundled relationship with other codes billed on the claim.
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 and when required the appropriate modifiers. In this case, this claim could not be paid as billed due to the omission of a required modifier and issues with bundled relationships between codes reported on the claim. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on August 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for disposable contact lenses (S0500), a prescription/fitting for 
standard contact lenses (92310), and fundus photography (92250) provided on August 26, 2022. 
 
You asked the Plan to pay for disposable contact lenses (S0500), a prescription/fitting for standard contact 
lenses (92310), and fundus photography (92250). You say that you feel the services provided were necessary 
for prevention for your health care needs. The Plan denied your request. The Plan says you are responsible for 
any amount over the $100 retail price for disposable contact lenses (S0500), and a prescription/fitting for 
standard contact lenses (92310). The Plan contract also says that there is no coverage for fundus photography 
(92250) under your routine or supplemental benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers $100 toward the purchase and fitting of contact lenses. Fundus photography is 
excluded from this benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers $100 toward the purchase and 
fitting of contact lenses. The record shows the Plan covered the $100 towards the purchase and fitting of 
contact lenses. The Plan rules also say that you are responsible for any amount over $100 toward the purchase 
and fitting of contact lenses. The record also shows that fundus photography is excluded from this benefit. 
Based on this information, we decided that the Plan's rules for coverage of disposable contact lenses (S0500), a 
prescription/fitting for standard contact lenses (92310), and fundus photography (92250) have not been met. 
Therefore, we decided that the Plan does not have to pay for disposable contact lenses (S0500), a 
prescription/fitting for standard contact lenses (92310), and fundus photography (92250) provided on August 
26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist visit provided on March 15, 2022. 
 
You asked the Plan to pay for specialist visit. 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 specialist visit provided 
on March 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 20, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that referral should not be required for this code. 
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). The referring provider is also out-of-network. Therefore, we decided that the Plan 
does not have to pay for the laboratory services provided on May 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on June 23, 2022. 
 
You asked the Plan to pay for diagnostic radiology services. You say that this patient is in a nursing home and 
this provider has an exclusive contract with the nursing home, which means this provider is the only provider 
that can come to the facility to perform the service. The Plan denied your request. The Plan says there is not an 
authorization or corresponding facility claim on file for this date of service. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for diagnostic radiology services provided on June 23, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient mental health services provided to the enrollee from 
September 6, 2022, to September 9, 2022. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that this was medically 
necessary. The Plan denied your request. The Plan says that care was more appropriate at the observation level. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our 
reviewer says that the services at issue in this case were medically reasonable and necessary. Our physician 
reviewer found that it was expected that this enrollee would improve in a reasonable period of time as he did 
have dangerousness to self but not others. The enrollee did have auditory but not visual hallucinations. It did 
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care 
rather than a lower level of care as he did have dangerousness to self but not others. It does appear that active 
treatment was taking place. It did appear that the records were supervised and evaluated by a physician. The 
health plans denial of inpatient psychiatric services appears inappropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pay for inpatient mental health services provided to the enrollee from September 6, 2022, to 
September 9, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 4, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. 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. This claim 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 May 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on September 01, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that this was medically necessary and should be 
covered. 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 a nursing facility visit 
provided on September 01, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Inogen portable oxygen concentrator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that reimbursement for oxygen equipment is limited to 36 
monthly rental payments. 
 
We looked at the file and Medicare rules. The requested service is an Inogen portable oxygen concentrator. 
Medicare covers only rental oxygen. A purchased oxygen concentrator is not covered. Therefore, we decided 
that the Plan does not have to pre-approve an Inogen portable oxygen concentrator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 22, 2021.
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 billing criteria were not met. Maximus overturned the Plans denial. The Plan states that Maximus did not apply the correct billing criteria. The Plan demonstrated that the records show this gene panel was billed with code 81479. The claim was also billed with a date of service inconsistent with Medicare rules governing laboratory services. The records show the specimens were collected on December 7, 2020, and December 28, 2020, rather than the billed date of service January 22, 2021. There is no documentation to support genetic testing with the billed date of service. The enrollee had Tempus gene panel testing billed with multiple code, including 81479 with a -59 modifier. This one code was submitted on its own on a separate claim form; the other codes were submitted on multiple different claim forms. However, testing was performed on the same specimens for each claim. 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. When laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, meaning one code must be submitted for the panel.
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 issues with the dates of service reported and the number of codes reported against the same specimen. 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 January 22, 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 December 14, 2021.
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. The Plan requested a reopen and demonstrated that the enrollee had Tempus Gene Panel testing billed with multiple codes, including 81479 with a -59 modifier. This one code was submitted on its own on a separate claim form; the other codes were submitted on a different claim form, but testing was performed on the same specimen. Medicare denies coverage 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. A panel constitutes a single procedural service, so one code must be submitted for the panel. Additionally, modifiers should not be used to report multiple codes when a single specimen is tested. This testing was done on a single blood/tissue specimen. Finally, the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on November 24, 2021, rather than the billed date of service December 14, 2021.
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 pad as billed due to issues with the dates of service reported and the inappropriate billing for multiple claims applied to the same specimen. 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 December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says The Plan has no record of the member having another 
dental plan and any overpayment credit due to the 
member would come from the provider not the plan. 
 
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 20% 
coinsurance for dental services.  
 
You have been asked to pay a 20% coinsurance for dental services. 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 
cost share for the dental services provided on July 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cateract procedure provided on August 03, 2022. 
 
You asked the Plan to pay for a cateract procedure. You say that this provider should be in network, as they are 
listed on the plans website. 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 a cateract procedure 
provided on August 03, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for echocardiogram (ECG) provided on July 
18, 2022. 
 
You asked the Plan to waive the copayment for ECG. You say that you disagree with the 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 $165 
copayment for outpatient diagnostic tests/Medicare-covered radiological diagnostic services.  
 
You have been asked to pay a $165 copayment for ECG. This item/service falls within the outpatient 
diagnostic tests/Medicare-covered radiological diagnostic services 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 echocardiogram (ECG) provided on July 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a CT scan with Fractional Flow Reserve (FFR) for the enrollee.
You asked the Plan to provide coverage for a CT scan with Fractional Flow Reserve (FFR). You say that at the time of the appeal, this treatment was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Fractional Flow Reserve (FFR). The Maximus Physician Reviewer determined that the requested scan was medically reasonable and necessary. The Plan requested a reopen and stated a calcium scoring test was not requested by the provider, and notes that the appealed FFR was not addressed. The Plan is correct in this case. The documentation does not support that the enrollee in this case was an intermediate-risk patient with acute or stable chest pain and with no known history coronary artery stenosis with finding of 40-90% in proximal or middle coronary artery on CCTA, or was an intermediate-risk patient with acute chest pain and known non-obstructive (<50%) coronary artery stenosis with finding of 40-90% stenosis in proximal or middle coronary artery on CCTA, or had stable nonobstructive coronary artery disease (<50% stenosis) with persistent symptoms requiring further test, and finding of 40-90% stenosis on CCTA. The documentation does not support that the coverage criteria for FFR were met 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 Fractional Flow Reserve (FFR) have not been met. Therefore, we decided that the Plan does not have to provide coverage for Fractional Flow Reserve (FFR) for the enrollee.