Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 25, 2023. 
 You asked the Plan to pay for the home health services. You say that you do not believe a NOA is required. 
The Plan denied your request. The Plan says the NOA was not received. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided on July 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on April 27, 2023. 
 
You asked the Plan to pay for the drug testing. You say that this testing 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 the drug testing 
provided on April 27, 2023.
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99285. We decided that the Plan does not have to pay for 93010.  
 
You asked the Plan to pay for emergency room services (procedure code 99285 and 93010) rendered on August 
14, 2023. You say that this should be paid for. The Plan says that the documentation received does not indicate 
that the visits were for unrelated reasons. 
 
We decided that the Plan has to pay for 99285.  
 
The Plan follows Medicare rules. Medicare rules say that services must be reported correctly. 
 
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 for CPT 93010. Our reviewer says that these two 
claims are not duplicates. The enrollee was evaluated twice on the same day, hours apart, for similar but 
different issues, with different outcomes. The earlier claim for CPT 93010 is supported, as the provider did 
review the enrollee's electrocardiogram (EKG). 
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for 99285.  
 
We also decided that the Plan does not have to pay for 93010. 
 
The Plan follows Medicare rules. Medicare rules say that services must be reported correctly. 
 
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 for later claim of CPT 99285. Our reviewer says that 
although this was not a duplicate, the medical decision was not of high complexity.  
 
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for 93010. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service August 14, 
2023.  
 
You asked the Plan to pay for procedure code 99232. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99232 is bundled into payment for code 99239. 
 
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 99232 
is a column two code to column one code 99239 with a modifier indicator of 0. The column two code is therefore not payable. 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 99232 billed for date of service August 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for an upgraded electronic connection for the enrollee.

You asked the Plan to provide coverage for an upgraded electronic connection. You say that at the time of the
appeal, these accessories were necessary. The Plan denied your request.

The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic
connection (E2311). The medical records show the enrollee is a 67-year-old woman with bilateral hip, knee,
and shoulder pain, as well as lower extremity spasticity and neuropathy. She has undergone bilateral total knee
arthroplasty, and spine surgery. The progress notes dated February 10, 2023, document that the enrollee was
ambulating short distances with a wheeled walker in the home. It was noted that she is able to transfer
independently. The Plan is correct in this case. The documentation supports that the enrollee's upper extremity
strength and function appear to be adequate to operate the power options using their own switches.

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 upgraded electronic connection have not been met. Therefore, we decided
that the Plan does not have to provide coverage for an upgraded electronic connection for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 80307 and G0483) 
rendered on May 9, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The CPT code manual definition of the denied codes is: 
 
CPT 80307: 
 
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service 
 
Healthcare Common Procedure Coding System (HCPCS) G0483: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that there are no results provided in 
the medical records. It is not clear that the services were rendered. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (procedure code 80307 and G0483) rendered on May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87481, 87640, 87653 and 87798) billed 
for date of service August 24, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this was a test panel which should be reported 
with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory panel (87481, 87640, 87653 and 87798) billed for date of service 
August 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) 
provided on August 15, 2023. 
 
You asked the Plan to waive the copayment for the magnetic resonance imaging (MRI). You say that you are 
on a fixed income and you cannot afford to pay the high copayment. 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 advanced radiology services. 
 
You have been asked to pay a $175 copayment for the magnetic resonance imaging (MRI). This item/service 
falls within the advanced radiology services 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 the magnetic resonance imaging (MRI) provided on August 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS Oral Brush Biopsy test provided on March 14, 
2023. 
 
You asked the Plan to pay for the WATS Oral Brush Biopsy. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing is not covered. 
 
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 determine if Medicare rules for coverage of the WATS Oral Brush Biopsy have 
been met. Specifically, no medical records or literature was provided to support the service at issue. Only lab 
results were submitted. No office or clinical notes were provided to support medical necessity of this service. 
Therefore, we decided that the Plan does not have to pay for the WATS Oral Brush Biopsy test provided on 
March 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49002 billed for date of service November 
13, 2022. 
 You asked the Plan to pay for procedure code 49002. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 49002 is bundled into payment for code 44130. 
 
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 49002 
is a column II code to column I code 44130. 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 49002 billed for date of service November 13, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 26, 2023, billed with 
code 81456. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. Review of the file shows that the enrollee also received services 
billed under code 81455. The records submitted indicate that the provider is requesting an additional code for a 
procedure that is part of another test that was performed. This means this was an NGS panel that was not billed 
with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of 
the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on July 26, 2023, billed with code 81456.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility office visit provided on August 31, 2023. 
 
You asked the Plan to pay for a facility office visit. You say that the enrollee is in a facility and the facility 
should have obtained the prior authorization. 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 facility office visit 
provided on August 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics (expandable controller, harness 
and electronic connector to two power options). 
 
You asked the Plan to pre-approve upgraded electronics. You say that you have been falling because your 
wheelchair is too big. You also say that the new chair and features will make things easier for you. The Plan 
denied your request. The Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are only covered for certain 
indications. 
 
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 upgraded electronics. Our reviewer says 
that the documentation does not support that the requested items are medically reasonable or necessary. Our 
physician reviewer found you have progressive lateral sclerosis. You are able to transfer independently with 
grab bars. You have three (3) to four (4) out of five (5) strength in your right upper extremities. The 
documentation shows that you have adequate strength to manage standard power drives. Therefore, you do not 
meet criteria for the requested upgraded electronics. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve upgraded electronics (expandable controller, harness and electronic connector to 
two power options).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on October 05, 2023. 
 
You asked the Plan to pay for physical therapy services. You say that these services were 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 
services provided on October 05, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the negative pressure wound therapy electrical pump 
(E2402) canister, disposable, used with suction pump (A7000) and wound care set (A6550) provided June 5, 
2023. 
 
You asked the Plan to pay for the negative pressure wound therapy electrical pump and supplies. You say that 
please process correctly and reconsider for correct payment. The Plan denied your request. The Plan says this is 
a work-related injury/illness and thus the liability of the Worker's Compensation carrier. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has that these 
services were due to a work-related injury/illness and the claim should be submitted to the Worker's 
Compensation carrier. As the secondary insurer, the Plan cannot be held responsible for the negative pressure 
wound therapy electrical pump and supplies until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the negative pressure wound therapy electrical 
pump (E2402) canister, disposable, used with suction pump (A7000) and wound care set (A6550) provided 
June 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (87640-59) provided August 9, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not supported by the records. 
 
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 87640 is a column II code to column I code 87641; however, 87640 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the laboratory service. Our reviewer found code 87640 is not 
supported as a separately identifiable procedure, the record shows that this is included in 87641 and should not 
be reported separately. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (87640-59) provided August 9, 2023.