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

 
We decided that the Plan does not have to pay for procedure code 77063 billed for date of service May 19, 
2022. 
 
You asked the Plan to pay for procedure code 77063. 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 77063 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 of 
procedure code 77063 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 77063 billed for date of service May 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal impacted cerumen requiring instrumentation 
(69210) provided on April 26, 2022. 
 
You asked the Plan to pay for the removal impacted cerumen requiring instrumentation. You say that you 
would like this service to be reprocessed for payment. The Plan denied your request. The Plan says the provider 
did not bill as required by Medicare coding regulations. The Plan also says that the requested additional 
information/medical records were not provided. 
 
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.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the removal impacted cerumen 
requiring instrumentation have been met. Medical records were not provided for this case. The record shows 
that the Plan made multiple attempts to obtain this information, but it was not received. Without this 
information we cannot determine that the service provided was billed as required by Medicare coding 
regulations. Therefore, we decided that the Plan does not have to pay for the removal impacted cerumen 
requiring instrumentation (69210) provided on April 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
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 noted that the records do not show that at the time of the request, the
enrollee had the physical ability to participate in IRF therapy.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that IRF admission is
covered only when it is medically reasonable and necessary as described in the Medicare rules section.
Medicare requires enrollees to be fully capable of participating in IRF therapy. Based on the medical records
provided, at the time of the request the enrollee had strict restrictions with sternal precautions and weight
bearing restriction.
Based on this information, Medicare rules for coverage of IRF care have not been met. Therefore, we decided
that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and
services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on
April 1, 2022.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you should not be
responsible to pay this because it was a screening colonoscopy, not a diagnostic colonoscopy. 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 $250
copayment for Medicare-covered surgical services in an ambulatory surgical center.
You have been asked to pay a $250 copayment for the diagnostic colonoscopy. This item/service falls within
the Medicare-covered surgical services in an ambulatory surgical center benefit category. The colonoscopy was
billed as diagnostic and not as a screening. Records from your provider also indicate that this was a diagnostic
colonoscopy. 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 the diagnostic colonoscopy provided on
April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transforaminal epidural injection (TFESIs) (64484) for
the enrollee.
You asked the Plan to pre-approve these services. You say that you would like reconsideration because the
requested injection is medically necessary. The Plan denied your request. The Plan says that you would like
reconsideration because the requested injection is medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The enrollee has
radicular low back pain. She has been treated with medical therapy and a home exercise program. It is not
considered medically reasonable and necessary to perform TFESIs at more than two (2) nerve root levels
during the same session. Our physician reviewer found that the enrollee's condition does not meet criteria for
coverage of these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve transforaminal epidural injection (TFESIs) (64484) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services (J3490, J0702, 62323) provided on June 
12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the injection services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
  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 injection services (J3490, J0702, 62323) provided 
on June 12, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service July 3, 2022. 
 
You asked the Plan to pay for procedure code 70544. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70544 is bundled into payment for code 70551. 
 
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 70544 is a column II code to column I code 70551. 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 70544 billed for date of service July 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for chiropractic treatments (98941) provided on 
January 4, 2022 to February 2, 2022. 
 
You asked the Plan to waive the deductible for the chiropractic treatments. You say that the services should be 
covered as you disagree with the denial. 
 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. Your 
contract with the Plan says that there is a $1000 deductible which applies to chiropractic services.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the Chiropractic services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 
deductible which applies to Chiropractic services. This cost sharing is a contractual obligation that had not been 
met at the time the chiropractic treatments was received on January 4, 2022 to February 2, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible for chiropractic treatments (98941) provided on 
January 4, 2022 to February 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from June 24, 2022, to 
June 27, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you did not know that you were 
admitted to the hospital under observation. You also say that you cannot afford this bill. The Plan denied your 
request. The Plan says self-administered drugs are not covered by Medicare or your healthcare plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from June 24, 2022, to June 27, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements 
for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that the enrollee has complex functional deficits with hip fracture and meniscal tear and active comorbidities. However, the evaluating physical 
therapist states that the enrollee is lethargic on dialysis days with fair rehabilitation potential. Thus, the enrollee 
would not be expected to participate in 15hrs of therapy per week. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx testing provided on June 21, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim for this molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the serivces have not 
been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx testing provided 
on June 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic services provided from September 3, 2021, to
November 8, 2021.
You asked the Plan for to pay for these services. You do not believe this bill is correct. The Plan denied your
request. The Plan says these services must be addressed under your Medicaid benefit. Maximus overturned the
Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim
denied under your Medicare benefit because you are Medicaid eligible. The Plan included documentation to
show that you are Medicaid eligible. These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information.
Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid,
but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage.
The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not
have to pay for diagnostic services provided from September 3, 2021, to November 8, 2021 under your
Medicare benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee from 
February 2, 2022, to February 5, 2022. 
 
You asked the Plan to pay for the items. You say that the doctor stated that these purchases were medically 
necessary. The Plan denied your request. The Plan says the item was obtained by a provider who is not under 
contract with the health plan and is not certified for Medicare. 
 
The plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program. 
 
The rendering provider not eligible to bill Medicare. The plan did not pre-approve the items. We found no 
exception that would require the plan to pay for these items. Based on this information, we decided that 
Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have 
to pay for durable medical equipment provided to the enrollee from February 2, 2022, to February 5, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the fixed wing air mileage and transport parking fees/tolls
provided to the enrollee on May 21, 2020.
You asked the Plan to pay for the fixed wing air mileage and transport parking fees/tolls. You say that there are
medically necessary inter-facility fixed-wing air ambulance transportation services which has an outstanding
balance that the Plan must cover. The Plan denied your request. The Plan says this claim is a duplicate of a
previously paid claim and was correctly denied.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied. However, such denials may be appealed.
We looked at the file and Medicare rules. The file includes evidence that the fixed wing air mileage (A4035) at
issue was reimbursed by the Plan on July 23, 2021. Comparison of the two claims shows these are exact
duplicates. There is no evidence presented to support that the billed items/services were provided twice on the
same date. In addition, the Plan is not required to pay code A0170 for parking fees and tolls. This cannot be
separately billed and is not on the Medicare feel schedule as a billable code. Based on this information, we
decided that the Medicare rules for the fixed wing air mileage and transport parking fees/tolls have not been
met. Therefore, we decided that the Plan does not have to pay for the fixed wing air mileage and transport
parking fees/tolls provided to the enrollee on May 21, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit coded 99284 provided on 
January 17, 2022. 
 
You asked the Plan to pay for the emergency department visit. 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. 
 
 
 In this case, the CPT Code Manual definition of code 99284 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not 
pose an immediate significant threat to life or physiologic function. 
 
We find that CPT code 99284 is not supported in the medical record. Specifically, this code was billed with 
modifier 25. This code cannot be reimbursed separately because this is not the appropriate modifier for a major 
surgery with a visit on the same date of service. This means this service is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of the emergency department visit have not been met. 
Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99284 
provided on January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 30, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital clinic visit and related services 
provided on June 7, 2022. 
 You asked the Plan to pay for the outpatient hospital clinic visit and related services. 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 find that CPT codes 70553, 92557, A9575, G0463, and G1004 are not supported in the medical record. 
Specifically, code G0463 is assigned HCPCS APC 5012 per Addendum B which has a status indicator of V per 
Addendum A for a clinic or emergency department visit. Billed procedure code 92557 is assigned 
HCPCS APC 5721 and procedure code 70553 is assigned HCPCS APC 5572 per Addendum B with both 
having a status indicator of S per Addendum A. HCPCS code G0463 was denied with OCE edit 21 for a 
medical visit on the same day as a Type T or S procedure and was not billed with modifier 25. 
Procedure code G1004 denied with OCE edit 112 as a non-covered service as it is for informational 
reporting purposes only and all remaining lines were denied with reason 0992 to correct OCE edit error 
on other claim line(s). Therefore, as HCPCS code G0463 was billed without modifier 25 and was billed 
on the same day as a Type S procedure was billed. 
 
Based on this information, we decided that Medicare rules for coverage of the outpatient hospital clinic visit 
and related services have not been met. Therefore, we decided that the Plan does not have to pay for the 
outpatient hospital clinic visit and related services provided on June 7, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 20, 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 for a
lack of claim information in the case file. The Plan requested a reopen and provided additional claim
information. The provided documentation to show referring provider ordered a PGx Complete 61 genes panel.
The Plan notes the lab performed and reported a Comprehensive Pharmacogenomic panel. CPT 81238 - F9
(coagulation factor IX), full gene sequence, which is not the correct code for the test ordered, performed and
reported.
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 there is a discrepancy between the actual test
ordered and the services performed. Therefore, we decided that the Plan does not have to pay for lab services
provided to the enrollee on May 20, 2021.