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

 
We decided that the Plan does not have to pay for procedure codes 88291 and G0452 provided on October 6, 
2022. 
 
You asked the Plan to pay for procedure codes 88291 and G0452. You say that the medical records support the 
use of modifier 59 with codes 88291 and G0452. The Plan denied your request. The Plan says the medical 
records do not support the use of modifier 59 with codes 88291 and G0452. 
 
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 codes 88291 and G0452 are column II codes to column I code 81339, 
81270 and 81219; however, 88291 and G0452 were billed with a modifier.  
 
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 88291 and G0452. Our reviewer says that 
the medical records do not support the use of modifier 59 with codes 88291 and G0452. Our reviewer found 
the medical record shows that the gene analysis is included in the accepted codes 81339, 81270, and 81219. 
There is no evidence that a separately reportable interpretation and report for a different cytogenic or molecular 
analysis was performed. Use of modifier 59 is not supported. 
 
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 88291 and G0452 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 88291 and G0452 provided on October 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
total shoulder arthroplasty and biceps tenodesis and will need inpatient admission after surgery. The Plan 
denied your request. The Plan says there is no documentation provided to support the expectation the enrollee 
will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   

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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a total shoulder arthroplasty and biceps 
tenodesis. The record does not document that the treating physician has a reasonable expectation of a length of 
stay spanning 2 or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a precision attachment (D5862). 
 
You asked the Plan to pre-approve a precision attachment (D5862). You say that you are not able to eat 
properly and are in need of the dentures. The Plan denied your request. The Plan says precision attachment is 
not covered under your dental benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
precision attachment (D5862).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 3, 2022, to January 4, 2022.

You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically necessary. The Plan denied your request. The Plan says that a lower level of care was more appropriate.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the low complexity and low severity of the presentation and workup, and expectation to have normal controlled blood pressure once the enrollee resumes their home maintenance medications, it was not expected that the enrollee would require hospital services that would likely cross two midnight's.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 3, 2022, to January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the evaluation and management service, identified by 
code 99397. 
 
You asked the Plan to pre-approve the requested services. You say that it is important to see this enrollee 
yearly. The Plan denied your request. The Plan says the service is not covered by Medicare or the Plan. 
 
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 99397 is periodic comprehensive preventive medicine 
reevaluation and management of an individual including an age and gender appropriate history, examination, 
counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic 
procedures, established patient; 65 years and older. We find that CPT code 99397 is not a service covered by 
Medicare. Based on this information, we decided that Medicare rules for coverage of the requested services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the evaluation and 
management service, identified by code 99397.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740x2), a core buildup, including any pins 
when required (D2950x3), a precision attachment (D5862), a complete lower overdenture (D5865), a surgical 
placement of an implant body: endosteal implant (D6010) and a retainer crown (D6750x3). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says your benefit for a surgical placement of an 
implant body, a crown, a retainer crown, and a core buildup has already been exhausted. A precision 
attachment and a complete lower overdenture are not covered by your Plan. 
 
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 the dental 
services when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Though the Plan offers a dental benefit in excess of Medicare 
coverage, certain limitations apply. The record shows your benefit for a surgical placement of an implant body, 
a crown, a retainer crown, and a core buildup are exhausted on the date of approval of services. The records 
also show that a precision attachment and a complete lower overdenture are not among those covered under 
this benefit. Based on this information, we decided that the Plan's rules for coverage of the dental services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740x2), a core 
buildup, including any pins when required (D2950x3), a precision attachment (D5862), a complete lower 
overdenture (D5865), a surgical placement of an implant body: endosteal implant (D6010) and a retainer crown 
(D6750x3).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on December 2, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. 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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided to the enrollee on December 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing (81455) provided on January 24, 2022.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for incomplete information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that the correct version of the LCA A56199 that was in effect from January 01, 2022, to March 31, 2022. This version was in effect when services were provided on January 24, 2022.
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 code. Code 81455 is covered to guide treatment decision making in individuals with non-small cell lung cancer.
Based on the medical records provided, this is not the enrollees reported diagnosis. 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 (81455) provided to the enrollee on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on September 2, 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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that the testing was performed on blood collected on December 29, 2021, and not on a biopsy specimen collected during a hospital encounter. The test was billed with place of service (POS) 81, which contradicts the assertion that the specimen was obtained during a hospital outpatient encounter. Therefore, the exceptions to the general rule for date of service would not apply in this case. Medicare rules say if an independent lab bills, the place where the sample was taken is shown. An independent laboratory taking a sample in its laboratory shows "81" as place of service. If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it uses the code for the inpatient (POS code 21), off campus-outpatient hospital (POS code 19), or on campus-outpatient hospital (POS code 22), respectively. 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 with 3 exceptions. None of those exceptions apply as the provider billed POS 81 not inpatient (21) or outpatient hospital (22)
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed due to errors with the dates of service billed and the POS code billed. 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 September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $15 copayment charged for specialist services provided on January 27, 2022.
You asked the Plan to waive this copayment. You say that you never used to have a copayment for a pacemaker check. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans denial because the case file lacked an appropriate Plan contract. The Plan requested a reopen and provided the required information.
The Plan is correct in this case. 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 $15 copayment for each specialist service. The copayment was charged based on the claim for payment submitted by your provider and the Plan contract rules.
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 $15 copayment charged for specialist services provided on January 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided to an enrollee during
and after a facility procedure on December 11, 2021.
You asked the Plan to pay for this claim. You say that the Plan should cover this equipment. The Plan denied
your request. The Plan says the 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 criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not pay any provider or
supplier other than the facility or hospital for services or equipment furnished to an enrollee. The facility or
hospital must furnish all necessary covered services to the enrollee either directly or under arrangements made
with outside providers. This equipment was used during and after a surgical procedure by the facility.
Payment for this service would have been included under the facility claim. Payment to you for this service is
the responsibility of the facility or hospital.
Therefore, we decided that the Plan does not have to pay for durable medical equipment provided to an enrollee
during and after a facility procedure on December 11, 2021.
Appeal type: Other
Decision: Unfavorable

We decided the Plan does not have to pay for orthoptic and/or pleoptic training provided out of network from May 24, 2022, to May 26, 2022.
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 services provided are not covered by Medicare and you did not have prior authorization for this out of network care.
Medicare rules say that plans can require enrollees to get prior authorization for both in network and out of network care. The contract with the Plan says that out of network care must be covered by Medicare, may need prior authorization, and will incur a higher cost to enrollees. You received out of network vision training services. You did not contact the Plan for prior authorization or to confirm the services provided were covered by the Plan or by Medicare. Therefore, we decided that the Plan does not have to pay for orthoptic and/or pleoptic training provided out of network from May 24, 2022, to May 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for shoulder arthroplasty provided to the enrollee on May 13, 2022.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and stated the issue was not medical necessity but the fact that the claim was submitted with modifier billing errors. The Plan noted that this claim denied because the provider billed this service with an inappropriate modifier. The claim billed with Modifier "LT" which shows this service was performed on the left side of the body. In addition, there are two new total shoulder revision codes, 23473 and 23474, that describe the revision of a total shoulder arthroplasty, which includes the removal of an artificial implanted prosthesis (ie, humeral and/or glenoid component[s]) and the replacement with a new implanted prosthesis in the same shoulder at the same time.
Based on the documentation provided the humeral portion of the previous arthroplasty was not addressed, the polyethylene component is part of the glenoid portion, and there is not any mention of removal of the humeral stem or glue. The records show replacement of the glenosphere and the polyethylene component.
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 the records provided do not support the claim details billed. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for shoulder arthroplasty provided to the enrollee on May 13, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing services provided to the enrollee on March 1, 2022.
You asked the Plan to pay for the genetic testing 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 genetic testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing services provided to the enrollee on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance charged for intraoral imaging (D0210) provided on June 21, 2022.
You asked the Plan to waive this coinsurance. You say that you do not believe this coinsurance is correct. The Plan denied your request. The Plan says this coinsurance was charged correctly. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted an intra oral x-ray of the entire mouth is covered once every 60 months. The Plan contract states enrollees pay 50% coinsurance for Class 2 Basic Services, which in this case was $44.82.
The Plan is correct in this case. Medicare generally does not cover dental services. The Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The contract clearly states there are benefit limitations for certain services and a coinsurance of 50% for Classic Basic 2 Services.
Therefore, we decided that the Plan does not have to waive the coinsurance charged for intraoral imaging (D0210) provided on June 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the mastectomy bra (L8000) and a breast prosthesis (L8020) provided on February 17, 2022, and a mastectomy bra (L8000) provided on March 10, 2022.
You asked the Plan to waive the coinsurance for the mastectomy bras and breast prosthesis. You say that you should not be responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plan's denial. The Plan requested a reopening stating that Maximus used the incorrect criteria. The Plan is correct in this case. The mastectomy bras and breast prosthesis are considered prosthetic devices and not durable medical equipment.
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 Prosthetic devices and related supplies.
You have been asked to pay a 20% coinsurance for the mastectomy bras and breast prosthesis. These items fall within the Prosthetic devices and related supplies 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 coinsurance for the mastectomy bra (L8000) and a breast prosthesis (L8020) provided on February 17, 2022, and a mastectomy bra (L8000) provided on March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on October 27, 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 insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that the provide billed six different codes for the comprehensive cardiovascular NGS panel. The billing guidelines state providers should report one unit of service for one genomic sequencing procedure.
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 code. In this case, this claim could not be billed because the codes submitted are not appropriate for the service provided. Multiple codes should not be billed when this type of testing is done with one 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 October 27, 2021.