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

We decided that the Plan does not have to pay for surgery services provided to the enrollee on November 15, 2021, and billed under code 37225-RT.
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 records provided do not support the services billed. Maximus overturned the Plans denial for a lack of medical records in the file. The Plan requested a reopen and submitted the records submitted with the claim. The Plan states that the code billed on the claim is not documented in the operative report narrative. According to Medicare billing code definitions and guidance, this case involves an inappropriate billing of code 37225-RT as this code is not supported in the documentation.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to support the billing definition for code 37225-RT. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for surgery services provided to the enrollee on November 15, 2021, and billed under code 37225-RT.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic imaging services provided to the enrollee on December 5, 2021, under code 71045.
You asked the Plan to pay for this claim. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient claim information in the case file. The Plan requested a reopen and stated that per National Correct Coding Initiatives (NCCI) a Procedure to Procedure (PTP) edit exists between code 71045 and 71046. This PTP edit has a modifier indicator of 1. Per National Correct Coding Initiatives (NCCI), the PTP edit between these two code pairs has a modifier indicator of "1" which states modifiers associated with NCCI are allowed. In this case an appropriate NCCI modifier was not billed on the claim. The Plan provided documentation to show procedure code 71046 was previously paid by the Plan on January 05, 2022, with check number L6416191.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that providers must submit claims with the appropriate codes and when necessary, the appropriate modifier. The Plan has provided documentation to show code 71046 was previously paid, and the claim for code 71045, was submitted without the required modifier. Medicare billing criteria are not met.
Therefore, we decided that the Plan does not have to pay for diagnostic imaging services provided to the enrollee on December 5, 2021, under code 71045.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on
February 16, 2022.
You asked the Plan to pay for the refraction. You say that ou thought an eye refraction exam would be covered.
The Plan denied your request. The Plan says that eye refractions are only covered by your plan if performed by
a participating vision provider and performed as a routine screening.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when performed by a Plan routine vision provider.
We looked at the file and the Plan's rules. The file indicates you did not get your refraction from a Plan routine
vision provider. Based on this information, we decided that the Plan's rules for coverage of the refraction have
not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state
(92015) provided on February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) panel provided to the enrollee on October 12, 2021.
You asked the Plan to pay for the F1CDx panel. You say that this testing is covered by Medicare and is medically necessary. The Plan denied your request. The Plan says that no Unique Test Identifier issued by Moldx is billed on the claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes, modifiers and in this case an identifier, based on the Medicare LCD guidelines applicable to the service. Medicare requires claims for this type of testing to be billed with a unique test identifier. We looked at the file and Medicare rules. Based on L35025, this requirement is applicable as the claim shows the lab test was rendered. The LCD indicates all tests billed within this jurisdiction are required to be billed with a "Unique Test Identifier." We find do not find this identifier was billed on the claim. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) panel provided to the enrollee on October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a K3 microprocessor (computerized) knee.
You asked the Plan to provide coverage for this request. You say that this prosthetic knee is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen stating Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a K3 microprocessor (computerized) knee. The Maximus Physician Reviewer determined the microprocessor knee was medically necessary. The Plan requested a reopen and argues that the medical records do not show a microprocessor knee is medically necessary. The medical records show you underwent a left above the knee amputation. You ambulate with bilateral axillary crutches. You with is to use a prosthesis. However, the Plan is correct in this case. A microprocessor knee is covered for enrollee's whose functional level is 3 or above. Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of knee. There is insufficient medical record documentation submitted by your providers to show a functional need for the technologic or design feature of the requested microprocessor knee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this request have not been met. Therefore, we decided that the Plan does not have to pre-approve a K3 microprocessor (computerized) knee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy provided to the enrollee on August 9, 2021.
You asked the Plan to pay for the psychotherapy. You say that the medical records prove medical necessity,
and the claim should be processed toward payment. The Plan denied your request. The Plan says that there was
no documented contact with the attending/primary care physician.
The Plan must follow Medicare rules. Medicare rules say that the CP must document, in the patient's medical
record, the date the patient consented or declined consent to consultations, the date of consultation, or, if
attempts to consult did not succeed, that date and manner of notification to the physician. The only exception to
the consultation requirement for CPs is in cases where the patient's primary care or attending physician refers
the patient to the CP.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of psychotherapy services have not been met. Specifically, the record does not include documentation
of a consultation or an attempt to consult the enrollee's primary/attending physician or a referral from the
enrollee's attending/primary physician as required by Medicare rules. Therefore, we decided that the Plan does
not have to pay for the psychotherapy provided to the enrollee on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with medical records to prove 
medical necessity. The Plan denied your request. The Plan says the enrollee must receive care from a network 
provider. 
 
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 an office visit provided on June 29, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from April 14, 2022, to May 5, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you did not know you needed to get a referral for 
these services. You also say your this is far too much for your Social Security income and you are requesting 
an exception. The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 psychotherapy provided from April 14, 2022, to 
May 5, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service February 9, 
2022. 
 
You asked the Plan to pay for procedure code 81345. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 81345 is bundled into 
payment for code 0089U. 
 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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service February 9, 
2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the endovenous ablation therapy provided on April 12, 2022.

You asked the Plan to pay for the endovenous ablation therapy. The Plan denied your request. The Plan says the coverage criteria are not met.

The Plan follows Medicare rules. Medicare rules say that varicose vein treatment is covered for the indication established in the applicable LCD.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the endovenous ablation therapy. Our reviewer says that the requested endovenous ablation therapy was not medically reasonable and necessary. Our physician reviewer found that the coverage criteria require that the patient remain symptomatic after 6-week trial of conservative therapy including the use of graduated compression stockings. The enrollee was prescribed compression stockings, however he did not obtain them. Additionally, there is no documentation that the enrollee was having activity limiting symptoms due to his varicose veins. The vein in question was less than 3 mm in diameter. In summary, in the absence of documentation of activity limiting symptoms and in the absence of a concerted effort at conservative care, the coverage criteria are not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the endovenous ablation therapy have not been met. Therefore, we decided that the Plan does not have to pay for the endovenous ablation therapy provided on April 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you currently work with a number of doctor 
groups who are participating providers and use your laboratory services exclusively. You also say that the 
patient does not come to your laboratory, so they are not using out-of-network benefits as their participating 
doctor sends your laboratory the specimen(s) to process. The Plan denied your request. The Plan says the 
enrollee must receive care from a network provider. 
 
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 June 29, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (81455).

You asked the Plan to pre-approve genetic testing. You say that this test was medically necessary and was completed in order to evaluate for other treatment options. The Plan denied your request. The Plan says the genetic test requested does not meet the requirements for approval.

The Plan must follow Medicare rules. Medicare rules say that the diagnostic laboratory test using NGS must have Food & Drug Administration (FDA) approval or clearance.

We looked at the file and Medicare rules. The records show that the provider requested a test that is not FDA approved. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81455).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service January 25, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 92960.  
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 93010 
is a column II code to column I code 92960. 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 93010 billed for date of service January 25, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the provider is employed by the hospital, and if the 
hospital is considered an authorized provider, then any services rendered by the provider would also be 
included in that authorization. The Plan denied your request. The Plan says the enrollee must receive care from 
a network provider. 
 
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 an office visit provided on May 3, 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 an office visit provided on February 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you should not be responsible to pay this. The Plan 
denied your request. The Plan says you must receive your care from a network provider. 
 
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 an office visit provided on February 28, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on January 28, 2022, to February 4, 2022, at the DRG originally billed.

 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the diagnosis of sepsis is supported by the physician's documentation and the information contained in the enrollee's medical records. You say that you disagree with the DRG reassignment, and the determination should be overturned. The Plan denied your request. The Plan says the diagnosis code for sepsis is not supported by the hospital records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.  

In this case, you billed the inpatient services provided with diagnosis code A41.01, defined as sepsis due to Methicillin susceptible Staphylococcus aureus. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says that the documentation does not support the diagnosis of sepsis. Our physician reviewer found that although evidence of systemic infection was present, it was not clearly sepsis. The Sepsis 3 criteria was not met as there was no evidence of organ dysfunction directly related to the infection. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided on January 28, 2022, to February 4, 2022, at the DRG originally billed.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve six (6) additional chiropractic visits. 
 
You asked the Plan to pre-approve additional chiropractic visits. You say that the member is showing 
worsening of condition and functional deficits. The Plan denied your request. The Plan says that the Plan has 
approved two (2) visits to finalize a home exercise program (HEP) and educate and reinforce importance of 
continued adherence to HEP post-discharge. The Plan says to deny six (6) visits as not reasonable and 
necessary. 
 
The Plan follows Medicare rules.  
 
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 six (6) additional chiropractic visits. 
Our reviewer says that the requested additional chiropractic visits are medically necessary. Our physician 
reviewer found that the enrollee has diagnoses of segmental and somatic dysfunction of the lumbar and sacral 
regions, and radiculopathy, lumbar region, with low back pain, unspecified. The enrollee has had 10 
chiropractic visits from June 8, 2022, through July 7, 2022. The Plan approved 4 plus 2 visits to finalize a home 
exercise plan. The examination findings on September 6, 2022 documents antalgic posture, asymmetry, tenderness and 7/10 pain. Worsening of the condition was documented, with functional deficits. The primary 
treatment was chiropractic manipulative treatment. On September 13, 2022 the provider writes that he does not 
think that the enrollee has reached her maximal medical improvement, and believes she needs further 
treatment. The enrollee's condition worsened with functional deficits, and further improvement is reasonably 
expected with additional chiropractic manipulation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of six (6) additional chiropractic visits. have been met. Therefore, we decided that 
the Plan has to pre-approve six (6) additional chiropractic visits.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.