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

 
We decided that the Plan does not have to pay for the Invitae Hereditary Cardiomyopathy Panel (81439). 
 
You asked the Plan to pay for the Invitae Hereditary Cardiomyopathy panel. You say that the test results will 
benefit the enrollee and the enrollees family. The Plan denied your request. The Plan says this testing is not 
covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of the Invitae Hereditary Cardiomyopathy panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the Invitae Hereditary Cardiomyopathy Panel (81439).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 77014 provided from September 30, 2021, to October 
1, 2021. 
 
You asked the Plan to pay for procedure code 77014. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says that this service is considered incidental to the 
enrollee's total episode of care. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided no clear explanation for the denial, no 
citation to support their decision and no supporting documentation. Therefore, we decided that the Plan has to 
pay for procedure code 77014 provided from September 30, 2021, to October 1, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continue skilled nursing facility (SNF) care
beyond August 19, 2022.
You asked the Plan to provide coverage for SNF care beyond August 19, 2022. You say that at the time of the
appeal, SNF admission was medically necessary. The Plan denied your request. The Plan says the Medicare
criteria for continued SNF coverage were not met.
Maximus administratively overturned the Plans denial for a lack of documentation of notice in the case file.
The Plan requested a reopen and provided a copy of the Notice of Non-Coverage signed on August 17, 2022.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care
in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
Based on the medical records provided, as of August 17, 2022, you no longer required daily skilled nursing or
daily skilled therapy service at an inpatient SNF level of care. Notice of non-coverage as of August 19, 2022,
was provided to you and signed by your spouse. Medicare rules for coverage of continued SNF care were not
met. Therefore, we decided that the Plan does not have to provide coverage for continue skilled nursing
facility (SNF) care beyond August 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 16, 2022, to 
February 14, 2022. 
 
You asked the Plan to pay for the home health services. You say that the NOA is on file. The Plan denied your 
request. The Plan says the claim has not been billed with the correct admission date. 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. The valid NOA has an admission date of January 16, 2022. We 
find that the admission date reported on the claim at issue does not match the date for the NOA which is filed 
for the first date in 2022 as required. Based on this information, we find that the Medicare rules for payment of 
the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from January 16, 2022, to February 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 4, 2022, to 
April 2, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim should be processed 
using the NOA dated January 3, 2022. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
  The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 4, 2022, to April 
2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary complete denture (D5110) provided on March 23, 2022.
You asked the Plan to pay for the dental services. You say that you were never told you could only get dentures every five years. 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 Plan's 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 December 11, 2019.
Therefore, we decided that the Plan does not have to pay for the maxillary complete denture (D5110) provided on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neurophysiology services provided to the enrollee on July 19, 2021 and billed under codes 95937 and 95957.
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 while a portion of this claim was paid, codes 95937, 95957, 95886 and 95908 do not meet the Medicare billing criteria. Maximus partially overturned the Plans denial for codes 95937 and 95957. The Plan requested a reopen and provided additional information regarding the billing issues with these codes. The Plan notes that train-of-four monitoring, or code 95937, is bundled with the intraoperative monitoring and therefore is not separately payable. Additionally, code "95937-26 x 4" is not supported by the medical records submitted. The technical report did not include documentation of a neuromuscular junction testing (repetitive stimulation, paired stimuli) for each nerve, by any 1 method; therefore, this code cannot be verified as billed. The Plan further stats per the National Correct Coding Initiative Policy Manual for Medicare Services, regarding code 95957-26, this code applies to computer digital analysis of an EEG as in cases of epilepsy. Procedure 95957 has both a technical and professional component. To claim only the professional component, append modifier 26. To claim only the technical component, append modifier TC. To claim the complete procedure (i.e., both the professional and technical components), the claim submits without a modifier. This code should not be reported for use of automated software. For use of automated spike and seizure detection and trending software when performed with long-term EEG, provider should see codes 95700-95726. This description was not documented in the operate report narrative.
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, we do not find the records provided fully support the billing of code 95957-26. We also find code 95937-26 x 4 also is not supported by the medical records and has a bundling relationship with other codes submitted on the claim.
Medicare rules for coverage of any of these services have not been met. Therefore, we decided that the Plan does not have to pay for neurophysiology services provided to the enrollee on July 19, 2021 and billed under codes 95937 and 95957.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 2, 2022, to 
January 7, 2022 at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the submitted records do not support the billing of diagnosis code A41.9. Our physician 
reviewer found the enrollee presented to the emergency department (ED) with weakness, falls, and diarrhea. 
The evaluation revealed stable vital signs except for tachycardia. The exam revealed a tender abdomen. He was 
treated for urosepsis with intravenous (IV) fluids and antibiotics. He was evaluated by Nephrology and was 
noted to have bilateral obstructive nephropathy from renal stones and benign prostatic hyperplasia. He 
remained hemodynamically stable and his condition stabilized and improved. There is no clinical or laboratory 
evidence of sepsis. The records do not support the billing of A41.9.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 2, 2022, to January 7, 2022 at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 8, 2021, to 
September 10, 2021 at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the 
billing of diagnosis code G93.41. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code G93.41. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the submitted records do not support the billing of diagnosis code G93.41. Our physician 
reviewer found the enrollee presented to the hospital status-post alleged drug overdose. The documentation 
stated she had acute metabolic encephalopathy after an intentional overdose on Ativan. The history and 
physical noted that she was alert, somnolent, but arouses and answers questions. The physician ordered a head 
computed tomography (CT) scan, which showed an old infarct with stable microvascular ischemia. The review 
of the medical record found no evidence of clinical symptoms or findings on physical exam consistent with a 
diagnosis of metabolic encephalopathy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 8, 2021, to September 10, 2021 at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transcatheter implantation of wireless pulmonary 
artery pressure sensor for long-term hemodynamic monitoring (33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that you are writing a request for 
coverage for implantation of a CardioMEMS heart failure system for the enrollee. You strongly believe that 
implantation of this device will enhance the care of this enrollee and enable you to reduce the risk of 
hospitalization. The Plan denied your request. The Plan says the clinical value and effectiveness of the 
CardioMEMS device has not been demonstrated in peer reviewed literature and there is no documentation that 
the enrollee is participating in a clinical trial for evidence development. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the transcatheter implantation of wireless pulmonary artery pressure sensor for long-term 
hemodynamic monitoring (33289).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgery to place two vertiflex superion devices 
(22869, 22870). 
 
You asked the Plan to pre-approve a surgery to place two vertiflex superion devices. You say that this service 
is medically necessary. The Plan denied your request. The Plan says this service is not 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 a surgery to place two vertiflex 
superion devices. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this service is considered experimental and more research 
is needed to shot its safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a surgery to place two vertiflex superion devices have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a surgery to place two vertiflex superion devices (22869, 
22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99213) with a neurologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you have seen this provider for treatment for 
epilepsy following brain surgery in the past. You also say you are in your first trimester of a high-risk 
pregnancy and this provider is helping you to prevent seizures while carrying the baby. The Plan denied your 
request. The Plan says there are no claims on file showing you have seen the requested provider since joining 
the plan in July 2022. Although neurology visits are available to you, this service can be received from 
providers 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 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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99213) with a neurologist to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the crowns provided on January 8, 2021.
You asked the Plan to provide additional payment for the dental services. You say that your crowns were pre-approved and should be covered. The Plan denied your request. The Plan says that your full $1,000 dental allowance has been applied to your claim.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up $1,000 every year for non-Medicare covered comprehensive dental services. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The file shows that the Plan has approved the maximum yearly benefit of $1,000 for the requested services.
There is no provision in the contract which would require the Plan to approve more than this amount. Therefore, we decided that the Plan does not have to provide additional payment for the crowns provided on January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 6, 2022, billed with 
codes 81223, 81302, 81330, 81332, 81345, 81404, 81405, 81406, 81407, 81479 and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and was 
reported correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. In addition, this claim was submitted with an incorrect place of service code. 
 
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. Medicare rules also say that, for lab services, the POS code must reflect 
the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Also, this claim was billed with the laboratory POS code. The records do not support that the 
sample was taken in a laboratory setting.  Based on this information, we decided that Medicare rules for 
coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to 
pay for the genetic testing provided on April 6, 2022, billed with codes 81223, 81302, 81330, 81332, 81345, 
81404, 81405, 81406, 81407, 81479 and 81408.
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 March 3, 2022.
You asked the Plan to pay for this testing. You say that this testing 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 for medical necessity. The Plan requested a reopen and stated the issue was not medical necessity but the fact that the claim had several billing errors. The Plan notes that the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that specimens were collected on February 2, 2022. The specimen was received on February 24, 2022. There is no documentation of molecular pathology testing performed on the date billed of March 3, 2022. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service. 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 did not include the required unique test identifier or DEX Z Code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim could not be paid as billed due to issues with the dates of service reported, the POS code reported and the omission of required codes. Medicare rules for coverage of this testing 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 March 3, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on August 3, 2021. 
 
You asked the Plan to pay for an emergency department visit. You say that you are unable to bill Medicare 
since Medicare does not process Freestanding Emergency Room claims. The Plan denied your request. The 
Plan says in order for a facility to receive reimbursement for a Medicare member, the facility must be enrolled 
to participate in the Medicare program. This facility is not enrolled to participate in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. Medicare says no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an emergency department visit provided 
on August 3, 2021.