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

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on July 22, 2021.
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. The
Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted that
the clinical information provided does not support coverage under NCD 90.2, therefore this test is statutory
excluded. National Coverage Determination (NCD) 90.2 offers coverage for this test in specific cases: Next
Generation Sequencing is reasonable and necessary only when the patient has: either recurrent, relapsed,
refractory, metastatic, or advanced stage III or IV cancer; and. either not been previously tested using the same
NGS test for the same primary diagnosis of cancer, or repeat testing using the same NGS test only when a new
primary cancer diagnosis is made by the treating physician; -decided to seek further cancer treatment (e.g.,
therapeutic chemotherapy). The diagnosis on the claim form (C61 - Malignant neoplasm of prostate) does not
support that this test was ordered for a condition for which it was validated. There is no diagnosis specific
indication for this test. Specifically, there is no evidence of myeloid neoplasm. There was not documentation of
recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. There is no documentation that
the patient has not been previously tested with the same test using NGS for the same cancer genetic content and
decided to seek further cancer treatment (e.ge., therapeutic chemotherapy). Therefore, Medicare coverage
criteria were not met.
The Plan is correct. The Plan must follow Medicare rules. Medicare rules say that providers must report
services correctly. In this case, the records provided with the claim did not support the services billed.
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 July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 17, 2022.
You asked the Plan to waive the copayment for the office visit. You say that you feel these bills should be covered because you are on a zero-copay low-income policy. The Plan denied your request. The Plan says that this has processed towards Medicaid benefits.
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.
The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services). 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 waive the copayment for the office visit provided on February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 21, 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 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 criteria. The Plan noted that the claim was billed with a date of service inconsistent with Medicare rules. The records submitted show that specimens were collected on January 13, 2022. The specimen was received on February 9, 2022. There is no documentation of molecular pathology testing performed on the billed date of February 21, 2022. The claim was also 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. There is no documentation that the sample was taken in the laboratory. The difference in date of collection and date received confirms that the was not collected directly by the laboratory. Finally, the claim was not submitted with the required unique test identifier or DEX Z-Code.
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 issue with the dates of service billed, the POS code and the omission of a required 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 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 2, 2021, billed with 
codes 81408, 81406, 81404, 81351, 81405, 81479, and 81401. 
 
You asked the Plan to pay for the billed genetic testing. You say that this was billed appropriately. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the billed genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 2, 2021, billed with codes 81408, 81406, 81404, 81351, 81405, 81479, and 81401.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the targeted genomic sequence analysis panel, solid organ neoplasm, 51 
or greater genes (81455) provided December 7, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that please review the following medical records to 
reconsider denial code 81455 for medical necessity. You believe these services were appropriate based on past 
medical history. The Plan denied your request. The Plan says that the service is experimental and 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the genetic testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found Genomic Sequential Analysis Panel will be considered reasonable and necessary in the 
evaluation of tumor tissue in the following clinical circumstances: Newly diagnosed patients with advanced 
(stage IIIB or IV) NSCLC, who are not treatable by resection or radiation with curative intent, and who are 
suitable candidates for therapy at the time of testing. Previously diagnosed patients with advanced (stage IIIB 
or IV) NSCLC, who have not responded to at least one systemic therapy, or who have progressed following 
resection. The patient must be a candidate for treatment at the time of the testing. Previously diagnosed patients 
with advanced (stage IIIB or IV) NSCLC, who have been resistant to at least one targeted therapy, are able to 
undergo tumor tissue biopsy for testing, and who are suitable candidates for additional treatment at the time of 
testing.  
 
In this case, the enrollee is diagnosed with metastatic Adenocarcinoma of the lung. Further treatment is being 
decided on pending the requested laboratory results. The review has determined that the items/services at issue 
in this case are medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have been met. Therefore, we decided that the Plan has to 
pay for the targeted genomic sequence analysis panel, solid organ neoplasm, 51 or greater genes (81455) 
provided December 7, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75716-59, 75774-59, and 99153 provided 
on August 9, 2022. 
 
You asked the Plan to pay for procedure codes 75716-59, 75774-59, and 99153. You say that the medical 
records support procedure codes 75716-59, 75774-59, and 99153. The Plan denied your request. The Plan says 
the medical records do not support procedure codes 75716-59, 75774-59, and 99153. 
 
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 75716 is Angiography, extremity, bilateral, radiological 
supervision and interpretation. The definition of code 75774 is Angiography, selective, each additional vessel 
studied after basic examination, radiological supervision and interpretation (List separately in addition to code 
for primary procedure). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 75716-59 and 75774-59 . Our reviewer says 
that the medical records do not support the use of modifier 59 with procedure codes 75716 and 75774. The 
documentation does not support that they were separately identifiable diagnostic procedures. Based on the 
documentation, 75716 and 75774 are included in the main procedure (37227) and should not be reported 
separately. 
 
Additionally, the review shows that the medical records provided represent professional charges; however, 
procedure code 99153 was provided in a facility with a place of service code of 21. Procedure code 99153 has a 
PC/TC Modifier Status of 3, which specifies a Technical Component only code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 75716-59, 75774-59, and 99153 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 75716-59, 75774-59, and 99153 provided on 
August 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the negative pressure wound therapy (e.g., vacuum 
assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing 
care, per session (97605). 
 
You asked the Plan to pre-approve the negative pressure wound therapy. You say that please reconsider 
approval for surgery as it is in the enrollee's best interest. The Plan denied your request. The Plan says Medical 
studies haven't proven this service/item is helpful in promoting healing after your shoulder joint replacement 
surgery. 
 
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 the negative pressure wound therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this enrollee is being treated for unspecified rotator cuff tear or rupture 
of the right shoulder. The enrollee presented with right shoulder pain and was last seen on June 21, 2022, for 
this issue. The enrollee received injections at that time with noted good relief. The symptoms have recently 
returned. It starts anteriorly and radiates down to the arm and into the hand. There is limited range of motion, 
and the enrollee has trouble with reaching and abduction. The exam reveals pain to palpation at the greater 
tuberosity. The range of motion is forward flexion 30, external rotation 25, and internal rotation to the hip. 
Neers and Hawkins are positive. 
 
The health plan has approved a reverse total shoulder arthroplasty (CPT 23472). However, there is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the noted pathology. She has a past surgical history of excision debridement of right knee 
nonhealing surgical wound, skin subcutaneous tissue, and fascia on 6/10/20. This correlates with the past 
medical history included venous stasis dermatitis of the bilateral lower extremities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the negative pressure wound therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the negative pressure wound therapy (e.g., vacuum assisted drainage 
collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session 
(97605).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to provide coverage for transfer from hospital to another for inpatient care.
You asked the Plan to provide coverage for this transfer. You say that at the time of the appeal this transfer was medically necessary for the enrollee. The Plan denied your request. The Plan says there is no indication in the medical records that the enrollees care cannot be provided at the originating facility. Maximus overturned the Plans denial stating inpatient care was medically necessary. The Plan requested a reopen and stated the inpatient care was approved, but the transfer to another facility was not demonstrated to be necessary.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare only covers hospital to hospital transfer if the facility the enrollee is being transferred to provides a treatment the enrollee requires that is not available at the current hospital. There is no indication in the medical records that the enrollee could not be treated at the originating facility. Medicare rules for coverage of this transfer were not met at the time of the appeal. Therefore, we decided that the Plan does not have to provide coverage for the requested transfer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vaccines provided on October 5, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for vaccines. You say that these services should be paid. The Plan denied your 
request. The Plan says services must be provided in-network. 
 
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 vaccines provided on October 5, 2022, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and intraoral imaging (D0210) provided on August 3, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you should not have to pay for this. The 
Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
benefit for D0210 was exhausted on November 19, 2021. Therefore, we decided that the Plan does not have to 
pay more for a comprehensive oral evaluation (D0150), prophylaxis (D1110), and intraoral imaging (D0210) 
provided on August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a complete 
series of radiographic images (D0210) provided on May 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 4, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a 
complete series of radiographic images (D0210) provided on May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014) and a determination of 
refractive state (92015) provided on September 22, 2022. 
 
You asked the Plan to pay for a medical eye examination (92014) and a determination of refractive state 
(92015). You say that you were not aware the provider was not in-network with the Plan. You also say that no 
one mentioned anything to you at your appointment. The Plan denied your request. The Plan says it was 
determined that vision services were rendered on 09/22/2022 by an out of network optometrist. 
 
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 these services when you use a provider in the Plan vision care network. 
 
We looked at the file and the Plan's rules. The Plan rules say that no referral is required for an annual routine 
eye examination, but you must use a provider in the Plan vision care network. Based on this information, we 
decided that the Plan's rules for coverage of a medical eye examination (92014) and a determination of 
refractive state (92015) have not been met. Therefore, we decided that the Plan does not have to pay for a 
medical eye examination (92014) and a determination of refractive state (92015) provided on September 22, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound (76882) provided on June 20, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that this service is supported as billed. The Plan denied 
your request. The Plan says this code is not supported in the medical record. 
 
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 76882 is ultrasound, limited, joint or other nonvascular 
extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue 
structure[s], or soft-tissue mass[es]), real-time with image documentation. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the ultrasound. Our reviewer found the documentation 
submitted was reviewed and does not meet criteria. The medical record does not include a radiology report to 
confirm ultrasound, limited, joint or other extremity structure was performed. Our reviewer unable to cite 
report, as this procedure was not found in medical record, and therefore, cannot be verified. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pay for the ultrasound (76882) provided on June 20, 2022.