Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mental health visit provided on May 17, 2022. 
 
You asked the Plan to pay for a mental health visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a mental health visit 
provided on May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, 88377, and 88381 
billed for date of service June 10, 2021. 
 You asked the Plan to pay for procedure codes 88341, 88342, 88360, 88377, and 88381. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says these codes are included in the 
facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, 88360, 
88377, and 88381. This means there is both a professional and technical component for the CPT codes. In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT codes 
88341, 88342, 88360, 88377, and 88381. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88341, 88342, 88360, 88377, and 88381 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 88341, 88342, 88360, 88377, and 88381 billed for date 
of service June 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic colonoscopy provided on 
September 26, 2022. 
 
You asked the Plan to waive the copayment for diagnostic colonoscopy. You say that this should be covered. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for outpatient surgery. 
 
You have been asked to pay a $325 copayment for diagnostic colonoscopy. This item/service falls within the 
outpatient surgery 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 copayment for diagnostic 
colonoscopy provided on September 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) scan 
provided on September 23, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI) scan. You say that you 
were told there were $0 copayments for MRIs with your Plan. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $175 copayment for a magnetic resonance imaging (MRI) scan. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for a magnetic resonance imaging (MRI) scan provided on 
September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on December 14, 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. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted that the claim was submitted with an incorrect POS code of 81, as the specimen clearly was not taken by the independent laboratory. In addition, the claim was not submitted with the unique test identifier or DEX Z-code required by Medicare.
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 an issue with the POS code billed and the omission of the required test identifier code. 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 December 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visits provided on February 09, 2022, to April 06, 
2022. 
 
You asked the Plan to pay for rest home visits. You say that services were rendered in good faith and should be 
compensated accordingly. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for rest home visits 
provided on February 09, 2022, to April 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
cone beam CT image capture with limited field of view (D0380), limited oral evaluation - problem focused 
(D0140), and retreatment of previous root canal therapy - premolar (D3347) provided on August 29, 2022. 
 
 You asked the Plan to pay for an intraoral - periapical first radiographic image (D0220), cone beam CT image 
capture with limited field of view (D0380), limited oral evaluation - problem focused (D0140), and retreatment 
of previous root canal therapy  premolar (D3347). You say that you felt like the endodontist would be in-
network like the dentist. The Plan denied your request. The Plan says your benefit for the requested items or 
services have already been exhausted, provided by an out-of-network provider, and are not covered by the 
Plans 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, certain limitations apply. The record 
shows your benefit for the intraoral - periapical first radiographic image (D0220) was exhausted on date of 
service February 14, 2022. Therefore, we decided that the Plan does not have to pay for an intraoral - periapical 
first radiographic image (D0220), cone beam CT image capture with limited field of view (D0380), limited oral 
evaluation - problem focused (D0140), and retreatment of previous root canal therapy - premolar (D3347) 
provided on August 29, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on September 26, 2022. 
 
You asked the Plan to pay for physical therapy. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
provided on September 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for MRI provided on October 05, 2022. 
 
You asked the Plan to pay for MRI. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for MRI provided on 
October 05, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Durable medical equipment provided on 
April 13, 2022, to September 14, 2022. 
 
You asked the Plan to waive the coinsurance for Durable medical equipment. You say that you cannot afford 
this charge. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for Durable medical equipment. This item/service falls within 
the durable medical equipment (DME) 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 Durable medical equipment provided on April 13, 2022, to September 14, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on July 19, 2022, to August 08, 
2022. 
 
You asked the Plan to pay for psychotherapy. You say that you are appealing this decision. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on July 19, 2022, to August 08, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on March 17, 2022 and billed under claim A with code 74019-26.
You asked the Plan to pay claim A. You say that this service 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. The Plan requested a reopen and provided additional information. The Plan noted that claim A denied because the Plan previously paid for this service under claim B to the same provider for the same date of service, under the same physician group. The medical records do not support why this procedure would have been rendered and/or billed twice on the same day. For payment consideration, the plan found the correct billing of this service needed to include modifier 59; which is used to distinguish a different session or patient encounter, or a different procedure or surgery, or a different anatomical site, or a separate injury.
The Medicare Claims Processing Manual, Chapter 23, Section 20.9.1.1 states: "MACs subject all line items
for the same beneficiary, same NPI, and same date of service to NCCI edits. All line items for the same
beneficiary, same NPI, and same date of service shall be subject to NCCI procedure-to-procedure (PTP)
edits." Both providers are with the same group (billing NPI).
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one
service is provided on the same day to the same patient by the same physician or more than one physician in
the same specialty in the same group, only one service may be reported unless the services are for unrelated
problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group
relationship between the two providers and the omission of the modifier required to identify this as a separate
and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have
to pay for imaging services provided to the enrollee on March 17, 2022, and billed under claim A with code
74019-26.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 23, 2022.
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. The Plan requested a reopen and provided additional information. The Plan notes that in addition to single gene testing, panels that include the FANCC and BLM genes is statutorily excluded service. The GTC-Hematology Profile panel which was ordered includes testing for FANCC and BLM. Further, there was no documentation of recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. The claim also included billing errors regarding the place of service code billed of 81, for Independent Laboratory, independent of an institution or a physician's office. This is incorrect as the specimen was collected in the hospital and not by the independent lab.
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 due to errors with the reported POS code and the statutory exclusion of the test due to Medicare coverage rules. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 18, 2022.
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. The
Plan requested a reopen and provided additional information. The Plan noted that this is an administrative
determination for billing and is not based on clinical criteria for medical necessity. 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. The specimen was
collected during an outpatient encounter and sent to the lab, therefore the POS code of 81 is not correct. In
addition, this test has not been cleared or approved by the Food and Drug Administration (FDA) and is not a
companion diagnostic for any therapy.
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 an error with the POS code
reported and the validity of the testing provide. 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
April 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (ECG) provided on September 29, 
2022. 
 
You asked the Plan to pay for an electrocardiogram (ECG). You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an electrocardiogram 
(ECG) provided on September 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for imaging services provided to the enrollee on February 3, 2022
under the Medicare benefit.
You asked the Plan for to pay for these services. The Plan denied your request. The Plan says these services
must be addressed under the enrollee's Medicaid benefit. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information. The Plan says that this claim denied under the
enrollee's Medicare benefit because they are Medicaid eligible. The Plan included documentation to show that
the enrollee was Medicaid eligible at the time of service. 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).
The Plan states these services qualified under the Medicaid benefit.
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. The Plan 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 the enrollee's
Medicaid coverage and not their Medicare coverage. The IRE does not have jurisdiction over the enrollee's
Medicaid benefits. Therefore, we decided that the Plan does not have to pay for imaging services provided to
the enrollee on February 3, 2022 under the Medicare benefit.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on December 1, 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. The Plan requested a reopen and provided additional information.
The Plan notes that while the test was billed on the date the report was signed, there is no documentation that the specimen was collected from a hospital outpatient during an encounter.
The claim form listed the 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. Therefore, the date of service for a clinical laboratory test or the technical component of physician pathology service must be the date of specimen collection. The exception to the general rule does not apply as the provider documented that the specimen was not obtained during a hospital outpatient encounter and was obtained by the laboratory directly. The claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show the specimen were collected on October 25, 2021. There is no documentation of molecular pathology testing performed on the date billed: December 1, 2021. There is also no documentation that the enrollee has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and has not been previously tested with the same test using NGS for the same cancer genetic content, and has decided to seek further cancer treatment (e.g., therapeutic chemotherapy).
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 claim could not be paid as billed due to issues with the POS code reported, the dates of services reported and the diagnosis of the enrollee not meeting coverage criteria. 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 December 1, 2021.