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

 
We decided that the Plan does not have to pay for procedure code G0452-26-59 provided July 20, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
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 G0452 is a column II code to column I code 81450; however, G0452 
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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The provider reported procedure code with appended modifier 59 
distinct procedural service to bypass NCCI Edit with billed service, CPT 81450 Targeted Genomic Sequence 
Analysis Panel; however, the medical record does not include documentation to support a medically necessary 
interpretation and written report, above and beyond the report of laboratory results. Therefore, this procedure 
cannot be verified. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code G0452-26-59 provided July 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the Shoulder-elbow-wrist-hand orthosis (SEWHO) (L3960) 
provided on June 28, 2023. 
 
You asked the Plan to pay for the SEWHO. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. There is no indication this item was needed, discussed, or ordered in the clinical documents 
submitted. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for  the Shoulder-elbow-wrist-hand 
orthosis (SEWHO) (L3960) provided on June 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service July 16, 
2023, to August 12, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that the provider referred the enrollee for the 
services rendered due to medical necessity. The Plan denied your request. The Plan says the billed code is 
invalid for Medicare purposes.  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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service July 16, 2023, to August 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81003 provided July 24, 2023. 
 
You asked the Plan to pay for the 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, the CPT Code Manual definition of code 81003 is urinalysis, by dip stick or tablet reagent for 
bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any 
number of these constituents; automated, without microscopy. 
 
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 service. Our reviewer found the record does not support 
that this test was performed.  
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 81003 provided July 24, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided June 5, 2023, to  
June 19, 2023, by an OON provider.  
 
You asked the Plan to pay for physical therapy. You say that you are appealing based on medical necessity. 
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 physical therapy services provided June 5, 2023, 
to June 19, 2023, by an OON provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service July 16, 
2023, to August 12, 2023. 
 
You asked the Plan to pay for procedure code S9328. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service July 16, 2023, to August 12, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97110, 97112, 97150, 97530 and 97116 
billed for date of service February 20, 2023, to February 28, 2023. 
 
You asked the Plan to pay for procedure codes 97110, 97112, 97150, 97530 and 97116. You say that all line 
items should be paid. The Plan denied your request. The Plan says these codes are not separately payable per 
Medicare rules. 
 
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 
97110, 97112, 97150, 97530 and 97116 are column II codes to column I codes 92507 and 97150. The records 
show that the services which have not been paid in this case are column II codes to column I codes billed on 
the same date, and no modifier was billed to bypass the NCCI 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 codes 
97110, 97112, 97150, 97530 and 97116 billed for date of service February 20, 2023, to February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491-59 and 87640-59 provided August 3, 
2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are 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 services. Our reviewer found for code 87491, 
the documentation submitted was reviewed and does not meet criteria. The medical record includes a signed physician order for laboratory services; however, the order does not include Chlamydia trachomatis was 
ordered, and therefore, cannot be verified. For code 87641, the documentation submitted was reviewed and 
does not meet criteria. The provider reported procedure code with appended modifier 59 distinct procedural 
service to bypass NCCI Edit with CPT 87641 Staphylococcus aureus, methicillin resistant, amplified probe 
technique.  Medical record does not include documentation to support separate billing for Staphylococcus 
aureus and Staphylococcus aureus, methicillin resistant, and therefore cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 87491-59 and 87640-59 provided August 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 31, 2023, to 
March 1, 2023. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the NOA was not received timely. 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 start of care date is January 31, 2023. The NOA was not received by the Plan until March 3, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 31, 2023, to March 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service July 16, 
2023, to August 12, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that code S9328 does not require authorization, 
and out-of-network benefits are available. The Plan denied your request. The Plan says the billed code is 
invalid for Medicare purposes.  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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service July 16, 2023, to August 12, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service May 2, 2023. 
 
You asked the Plan to pay for procedure code 99284. The Plan denied your request. The Plan says payment for 
code 99284 is bundled into payment for code 99285.  
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 99284 
is a column II code to column I code 99285. 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 99284 billed for date of service May 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491-59 and 87640-59 provided May 10, 
2023. 
 
You asked the Plan to pay for the laboratory services . You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are 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 services. Our reviewer found the record does 
not support that the services in question were performed as billed.  

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 services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 87491-59 and 87640-59 provided May 10, 2023.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99285, J1885, 96374) provided to
the enrollee on August 7, 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 stated that Maximus did not apply the correct billing criteria. The Plan
demonstrated that per Medicare Claims Processing Manual, Chapter 3, Section 40.3 - Outpatient Services
Treated as Inpatient Services, all outpatient nondiagnostic services, other than ambulance and maintenance
renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital)
on the date of a beneficiary's inpatient admission are deemed related to the admission and are billed with the
inpatient stay.

Per these Medicare guidelines, all outpatient non-diagnostic services provided by the hospital on the date of a
beneficiary's inpatient admission are deemed related to the admission and must be billed with the inpatient
stay.

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, these services cannot be billed separately based on the Medicare billing
guidelines as they would be pain within the inpatient stay. Medicare rules for coverage of these services have
not been met. Therefore, we decided that the Plan does not have to pay for emergency room services (99285,
J1885, 96374) provided to the enrollee on August 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 27602, 34151 and 34201 billed to the
enrollee for date of service June 14, 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 discrepancy in the reported providers prevents payment of the claim. Maximus
overturned the Plans denial stating the records show the services were performed. The Plan requested a reopen
and stated they agree the services were performed, but the issue was with the reported providers.
The Plan noted that there is no indication that the billing provider performed these services. The Plan states the
claim indicates one servicing provider (Provider A), but the operative report indicates another servicing
provider (Provider B). Due to the discrepancy, the Plan is unable to determined who assisted the surgery.

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. Medicare rules say that any claim with incomplete, missing, or invalid
information should be returned as un-processable. In this case the claim submitted does not reflect the same
provider as the medical record. Therefore, we decided that the Plan does not have to pay for procedure codes
27602, 34151 and 34201 billed to the enrollee for date of service June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 18, 
2023, to July 15, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that the provider referred the enrollee for the 
services rendered due to medical necessity. The Plan denied your request. The Plan says the billed code is 
invalid for Medicare purposes.  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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service June 18, 2023, to July 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service July 16, 
2023, to August 12, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that the provider was granted a waiver and 
approval for code S9328. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes.  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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service July 16, 2023, to August 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the traction equipment, cervical, free-standing stand/frame, 
pneumatic, applying traction force to other than mandible (E0849) provided June 24, 2023. 
 
You asked the Plan to pay for the traction equipment. You say that please see the attached medical records. The 
Plan denied your request. The Plan says the diagnosis on the records doesn't match the diagnosis on the 
prescription.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the traction equipment. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation from the physician does not fulfill criteria that traction equipment 
was medically necessary. 
 
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 traction equipment have not been met. Therefore, we decided that the Plan 
does not have to pay for the traction equipment, cervical, free-standing stand/frame, pneumatic, applying 
traction force to other than mandible (E0849) provided June 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee was only noted to have a 
form of dementia. However, there was no indication that the diagnostic criteria for either - let alone both - 
Alzheimer's Disease and frontotemporal dementia had been met/satisfied. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.