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

We decided the Plan does not have to pay for laboratory services (86301) provided on May 24, 2021.
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 are not met. Maximus overturned the Plans
denial. The Plan requested a reopen and provided additional information. The Plan states this claim denied as
suspect duplicate service because the Plan already paid for this service under another claim. The appealed
claim was billed inappropriately and did not support why this procedure had been rendered twice on the same
day. This denied only for "suspect" duplicates and not "exact" duplicates. The provider needed to bill with
Modifier 26 to show the service provided was the reading and interpreting of the results of a diagnostic and/or
laboratory service; orr with Modifier 91 to show the laboratory test(s) were performed more than once on the
same day on the same patient. According to the Medicare Claims Processing Manual, Chapter 1 - General
Billing Requirements - Section 120 - Detection of Duplicate Claims, explains "The claims processing systems
contain edits which identify exact duplicate claims and suspect duplicate claims. All exact duplicate claims or
claim lines are auto denied or rejected (absent appropriate modifiers). Suspect duplicate claims and claim lines
are suspended and reviewed by the claims administration contractors to decide to pay or deny the claim or
claim line."
The Plan further shows that Section 120.3 - Suspect Duplicates, states "Suspect duplicates are claims or claim
lines that contain closely-aligned elements sufficient to suggest that duplication may be present and, as such,
require that the suspect claim be reviewed. Suspect duplicate edits can be hard coded in the system or local
edits set up by Medicare contractors." And "The criteria for identifying suspect duplicate claims submitted by
physicians and other suppliers are not published and vary according to the type of billing entity, type of item or
service being billed, and other relevant criteria. The denial of claim as a duplicate of another claim may be
appealed when the denial is based on criteria other than those specified above for exact duplication." Based on
these guidelines, the Medicare billing criteria were not met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes and when necessary, the
appropriate modifiers. In this case, this claim cannot be paid due to the omission of a required modifier.
Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does
not have to pay for laboratory services (86301) provided to the enrollee on May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the panoramic 
radiographic image (D0330), and the extractions, of an erupted tooth or exposed root (D7140 x 6) rendered by 
the out-of-network (OON) provider on April 13, 2021 and August 26, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150), the panoramic radiographic image 
(D0330), and the extractions, of an erupted tooth or exposed root (D7140 x 6) rendered by the out-of-network 
(OON) provider on April 13, 2021 and August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dentures (D5110, D5214). 
 
You asked the Plan to pre-approve dentures. You say that this should be covered. The Plan denied your request. 
The Plan says this is not included in your dental benefits. 
 
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 
dentures (D5110, D5214).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay this claim as billed.
You asked the Plan to pay for these services. You say that these services should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. Maximus partially overturned the Plans denial
for insufficient claim information in the case file. The Plan requested a reopen and provided the required
information. The Plan demonstrated that code 99232 for date of service March 1, 2021, and procedure codes
50715-59 and 44140 for date of service March 4, 2021, received were denied for records requested were not
received on July 15, 2021. Records have now been received and procedure code 99232 for date of service
March 1, 2021, and procedure codes 50715-59 and 44140 for date of service March 4, 2021, have been routed
to the correct team for review of the New and Material Evidence and will be handled as an OD Reopen in
accordance with Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals
Guidance Section 80.5. OD Reopen case AT-2117349-M was finalized and procedure code 99232 for date of
service March 1, 2021, and procedure codes 50715-59 and 44140 for date of service March 4, 2021, were
processed on November 05, 2021.
Procedure code 99232 for date of service March 1, 2021, was processed and paid. Procedure code 44140 for
date of service March 4, 2021, was processed and paid. Proof of payment was submitted with the reopen.
Procedure code 50715-59 for date of service March 4, 2021, was denied as this code is not separately paid. A
copy of the Provider Remittance Advice that shows all three codes being processed on November 05, 2021,
was also submitted with the reopen request.
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 the Plan has
provided documentation to show portions of the claim were paid and that other portions were denied as not
being separately payable per Medicare billing guidelines. Therefore, we decided that the Plan does not have to
pay for the inpatient physician visits provided from March 1, 2021, through March 3, 2021, billed with codes
99232, and the surgical services provided on March 4, 2021, billed with codes 44140, 49000-59, and 50715-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 billed for date of service December 
23, 2021. 
 You asked the Plan to pay for procedure code G0453. You say that payment of code G0453 is allowable when 
billed with code 95955 when billed with a modifier. The Plan denied your request. The Plan says payment for 
code G0453 is bundled into payment for code 95955. 
 
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 G0453 
is a column II code to column I code 95955. 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 G0453 billed for date of service December 23, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal system, below knee, alignable system 
(L5910). 
 
You asked the Plan to pre-approve an endoskeletal system, below knee, alignable system (L5910). You say that 
the requested addition, endoskeletal system, below knee, alignable system (L5910) is medically necessary. The 
Plan denied your request. The Plan says the requested addition, endoskeletal system, below knee, alignable 
system (L5910) 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 an endoskeletal system, below knee, 
alignable system (L5910). Our reviewer says that the requested addition, endoskeletal system, below knee, 
alignable system (L5910) is not medically necessary.  Our physician reviewer found the requested endoskeletal 
system, below knee (BK), alignable system, exceeds the enrollee's medical need and is not medically necessary as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The requested item exceeds the enrollee's medical need as the 
enrollee's current approved preparatory prosthesis is non-alignable and at this time the alignable system is not 
appropriate for the enrollee's function with the preparatory prosthesis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an endoskeletal system, below knee, alignable system (L5910) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an endoskeletal system, below knee, 
alignable system (L5910).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 21, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
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 the office visit provided on June 21, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation provided on January 4, 2022, billed 
with code 99152. 
 
You asked the Plan to pay for the moderate sedation. You say that this claim should be paid due to medical 
necessity. The Plan denied your request. The Plan says the procedure itself was approved; however, the 
documentation does not support the billing of moderate sedation. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
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 moderate sedation. Our reviewer says that the code 
99152 is not supported by the submitted records. Our reviewer found a procedure report for Gastrostomy tube 
placement performed on date of service billed. However, procedure report does not include documentation of 
moderate sedation, and therefore, code 99152 cannot be confirmed.  
 
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 moderate sedation have not been met. Therefore, we decided that the Plan 
does not have to pay for the moderate sedation provided on January 4, 2022, billed with code 99152.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on February 10, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy. 
 
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, the service provided in this case is not 
among those covered under this benefit.  
  
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on 
February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99374 billed for date of service June 18, 
2021. 
 
You asked the Plan to pay for procedure code 99374. You say that it was medically necessary for the provider 
to review the patient's medications and home health plan of care. The Plan denied your request. The Plan says 
this is not a separately payable code. 
 
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 code 99374 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99374 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99374 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99374 billed for date of service June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for codes 99053 and 99220 provided April 13, 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 while code 99217 was paid, code 99220 was handled separately, and the remaining
portion of the claim was denied. Maximus partially overturned the Plans denial for a lack of documentation to
show the outcome of code 99220. The Plan requested a reopen and provided additional information. The Plan
states that appeal received on October 14, 2021, was for procedure code 99220 for date of service April 12,
2021, and for procedure codes 99217 and 99053 for date of service April 13, 2021. The Waiver of Liability
included with the appeal only listed date of service April 12, 2021. As such, the two dates of service were
addressed separately. Procedure codes 99217 and 99053 were addressed under Case AT-2287962-K for date of
service April 13, 2021, and a valid Waiver of Liability for date of service April 13, 2021, was requested from
the provider. New case AT-2261842-C was created to address procedure code 99220 for date of service April
12, 2021, as we had a valid waiver for that date of service. Case AT-2261842-C was finalized, and procedure
code 99220 was processed and paid on November 11, 2021. A copy of the paid Provider Remittance Advice
was submitted with the reopen request.
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 documentation provided shows code 99220 was paid. Code 99053 has a status indicator of B.
This means that the payment for CPT code 99053 is always bundled into the payment for another service or
procedure. Separate payment is not made. Therefore, we decided that the Plan does not have to pay the services
provided between 10:00 PM and 8:00 AM at 24-hour facility.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment of this claim. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 19, 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 services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network genetic testing provided to the enrollee on
May 4, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network lab services. Maximus
overturned the Plans denial as the case file lacked an Evidence of Coverage or Plan contract to confirm out of
network rules. The Plan requested a reopen and provided the required Evidence of Coverage.
The Plan is correct in this case. 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 Plan contract also states
outpatient lab services may require prior authorization both in and out of network.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for out of network genetic testing provided to the enrollee on May 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) supplies provided on 
September 24, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for DME supplies. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
 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 the durable medical equipment (DME) supplies 
provided on September 24, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share applied for physician services
provided on September 14, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was applied based on the Plan contract agreement and the
services provided. Maximus overturned the Plans denial.
The Plan requested a reopen and stated that Maximus did not apply the correct contract language. The Plan
states that the statement by Maximus that these services do not apply to the deductible is not correct. The codes
billed by the provider were 11301 and 11306 which are surgical codes. Therefore, the application of cost share
by the Plan was correct.
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 deductible and cost share billed outpatient surgical services. You have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the cost share applied for physician services provided on September 14, 2021.