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

 
We decided that the Plan does not have to pay for procedure codes 87481, 87798, 87640, 87651, 87653, and 
87801 billed for date of service November 8, 2021. 
 You asked the Plan to pay for procedure codes 87481, 87798, 87640, 87651, 87653, and 87801. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says payment for code 87481, 
87798, 87640, 87651, and 87653 is bundled into payment for code 87801. 
 
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 
87481, 87798, 87640, 87651, and 87653 are column II codes to column I code 87801. This claim has not been 
billed with an appropriate modifier to bypass the edit. We find that CPT code 87801 is not supported in the 
medical record. Specifically, the submitted medical records do not contain sufficient information support 
multiple organisms. This means code 87801 cannot be verified. 
 
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 codes 87481, 87798, 87640, 87651, 87653, and 87801 billed for date of 
service November 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) services provided on November 8, 2021, under the Medicare benefit.
You asked the Plan for to pay for these services. You say that you do not believe this bill is correct. The Plan denied your request. The Plan says these services must be addressed under your Medicaid benefit. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort.
Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services). These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to pay for these services under the Medicare benefit.
Appeal type: Lab
Decision: Favorable

We decided the Plan has to pay for outpatient hospital lab services (80050 General Health Panel) provided on November 10, 2021.
You asked the Plan to pay for outpatient hospital lab services (80050 General Health Panel). You say that these services should be covered by the Plan, The Plan denied your request. The Plan says that a general health panel is not covered by Medicare. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and stated that the required information was submitted, and that Medicare does not cover the cost of a general health panel.
While the Plan is correct that a general health panel is not covered by Medicare, these services were ordered by and provided by an in-network or contract provider. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred these services by a contract provider. The file does not show that the Plan or the provider gave you prior notice that these services would not be covered. Under Medicare rules, this means these services (minus your $50 copayment) are considered approved by the Plan. Therefore, we decided that the Plan has to pay for outpatient hospital lab services (80050 General Health Panel) provided on November 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (U0003, U0005) provided on March 7, 
2022. 
 
You asked the Plan to pay for laboratory services. You say that you want the Plan to pay for these services. The 
Plan denied your request. The Plan says the enrollee was enrolled in a federal hospice program during the time 
services were rendered. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services (U0003, U0005) provided on March 7, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 22, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this code should be paid. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74177 billed for date of service April 4, 
2022. 
 You asked the Plan to pay for procedure code 74177. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 74177 is bundled into payment for 
code 74174. 
 
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 74177 
is a column II code to column I code 74174. 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 74177 billed for date of service April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasound coded 76642 provided on September 
16, 2021. 
 
You asked the Plan to pay for the breast ultrasound. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not separately payable. 
 
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 76642 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; limited. 
 
We find that CPT code 76642 is not supported in the medical record. Specifically, this code was billed on the 
claim twice, on two different rows. The documentation shows that a bilateral breast ultrasound was provided. 
This means modifier 50 is the appropriate modifier for this service. Therefore, this code billed with modifier 
RT (right) is not payable. Based on this information, we decided that Medicare rules for coverage of the breast 
ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the breast 
ultrasound coded 76642 provided on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an office visit provided on February 15, 2022. 
 
You asked the Plan to reimburse you for an office visit. The Plan denied your request. The Plan says you did 
not submit an itemized receipt for the services rendered. 
 
The Plan contract says to send us your request for payment, along with your bill and documentation of any payment 
you have made.  
 
We looked at the file and the Plans rules. The file shows that you have not submitted an itemized receipt to the 
Plan. Therefore, we decided that the Plan does not have to reimburse you for an office visit provided on 
February 15, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for transfer from an inpatient rehabilitation facility (IRF) to a skilled nursing facility (SNF).
You asked the Plan to provide coverage for this transfer. You say that at the time of the appeal, transfer from and IRF to a SNF was medically necessary. The Plan denied your request. The Plan says the records show you could have been treated at the IRF until you were ready for discharge to outpatient care.
Maximus overturned the Plans denial and stated at the time of the appeal, you did not have documented skilled therapy needs. Maximus also stated it appeared that at the time of the appeal you were at or near a plateau in physical function. Maximus also stated daily skilled services were not required to establish a maintenance program or to prevent deterioration of your condition.
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 records provided, you were at or near plateau at the time of the appeal. You did not require an inpatient level of care in either an IRF or a SNF for daily skilled therapy or daily skilled nursing services. Any further care needed could have been provided at an outpatient level of care. Therefore, we decided that the Plan does not have to provide coverage for transfer from an IRF to a SNF.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a therapeutic 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eye surgery with an ophthalmologist to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve eye surgery with an ophthalmologist. You say that the enrollee needs to see 
a retina specialist and surgery is scheduled. The Plan denied your request. The Plan says you must use network 
providers to get your medical care and services when there are network providers available. 
 
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 
eye surgery with an ophthalmologist to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen; 
without contrast material, followed by contrast material(s) and further sections (74170) to be provided by an 
out-of-network (OON) facility. 
 
You asked the Plan to pre-approve a CT scan of the abdomen. You say that the requested CT scan is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested facility is not in network 
with the enrollee's plan. The enrollee must use network providers/facilities to get her medical care and services. 
 
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 
a computed tomography (CT) scan of the abdomen; without contrast material, followed by contrast material(s) 
and further sections (74170) to be provided by an out-of-network (OON) facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on January 
25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility (SNF) services. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 skilled nursing facility (SNF) services provided on 
January 25, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 16, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this code should be paid. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
hypoxemia, dizziness, and a fall. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 6, 2022, by an out- 
OON provider. 
 
You asked the Plan to pay for laboratory services. You say that you are submitting medical records requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the out-of-network services 
were not authorized. 
 
 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 laboratory services provided on January 6, 2022, 
by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided on December 10, 2021, under the Medicare benefit.
You asked the Plan to pay for these services. You do not believe the bill is correct. The Plan denied your request. The Plan says these services must be addressed under your Medicaid benefit. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services). These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to pay for these services under the Medicare benefit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood transfusion services provided from January 15, 2021, to January 17, 2021, coded as 36430.
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 are not met. Maximus overturned the Plans denial for insufficient documentation in the case file. The Plan requested a reopen and provided additional information. The Plan showed that per the National Correct Coding Initiatives (NCCI), a Procedure to Procedure (PTP) edit exists between 36430 and 49450, also billed. This PTP edit has a modifier indicator of 1, modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. The Plan upheld the denial as the provider did not bill as required by Medicare coding regulations.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say providers must report services with the appropriate codes and when required the appropriate modifier. In this case, this claim cannot be paid as billed due to the omission of a required modifier. Medicare rules for coverage of these services are not met. Therefore, we decided that the Plan does not have to pay for the blood transfusion services provided from January 15, 2021, to January 17, 2021, and billed under codes 36430.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on September 29, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing is consistent with the standard of 
care practice guidelines. The Plan denied your request. The Plan says a modifier is required. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the pathology testing was furnished to the enrollee is an outpatient hospital setting. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the pathology services provided on September 29, 2021.