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

We decided that the Plan does not have to pay for the definitive drug testing of up to 7 drug classes (G0480) provided to the enrollee on June 16, 2021.
You asked the Plan to pay for the definitive drug testing. You say that the services at issue have been billed correctly. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. Maximus overturned the Plan's denial. The Plan requested a reopening and provided additional documentation.
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the definitive drug testing have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for the definitive drug testing of up to 7 drug classes (G0480) provided to the enrollee on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the discharge services (99238) provided to the enrollee on July 28, 2021.
You asked the Plan to pay for the discharge services. You say that per the records only one hospital discharge was billed on this date of service. The Plan denied your request. The Plan says that they have already paid a for a hospital discharge date management service on this date of service. Maximus overturned the Plan's denial for lack of documentation. The Plan requested a reopening, stated that only one hospital discharge service can be paid and provided claim documentation to confirm they have provided payment for hospital discharge services on this date of service. The Plan is correct in this case. Medicare rules say that only one hospital inpatient or observation discharge day management service is payable per patient per hospital stay.
The claim document shows the Plan has already paid for one discharge service (99239) provided on July 28, 2021. The Plan cannot be required to pay for a second hospital discharge service for the same date of service.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the discharge services have not been met. Therefore, we decided that the Plan does not have to pay for the discharge services (99238) provided to the enrollee on July 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cystourethroscopy services (52352) provided on April 18, 
2023. 
 
You asked the Plan to pay for cystourethroscopy services. You say that this service is separately payable. The 
Plan denied your request. The Plan says this code is not denied; rather payment is adjusted and included in the 
payment for codes 52356 and base code 52351. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that when a service contains an indicator of 3, in Field 21, and multiple endoscopies are billed, the 
special rules for multiple endoscopic procedures apply. Pay the full value of the highest valued endoscopy, plus 
the difference between the next highest and the base endoscopy.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 52351 have not been met. Specifically, multiple surgical procedures were reported 
for this enrollee on the same date of service. The code at issue has an indicator of 3 in Field 21. Payment was 
issued for these services bundled as multiple surgeries. Therefore, we decided that the Plan does not have to 
pay for cystourethroscopy services (52352) provided on April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab test 87640-59 provided on March 23, 2023. 
 
You asked the Plan to pay for 87640-59. You say that the coding and diagnosis are both approved by Medicare. 
The Plan denied your request. The Plan says this code is included in 87641 and the record does not support the 
use of modifier -59. 
 
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 87640-59 is infectious agent detection by nucleic acid 
(DNA or RNA); Staphylococcus aureus, amplified probe technique. 
 
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 87640-59. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the approved procedure code 87641 includes the services performed in 87640. Medical documentation does not support the procedure being separate and distinct from the approved 
87641. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87640-59 have not been met. Therefore, we decided that the Plan does not have 
to pay for lab test 87640-59 provided on March 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 11, 2022, billed 
with codes 81294, 81292, 81295, 81297, 81298, and 81317. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the 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. 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 
November 11, 2022, billed with codes 81294, 81292, 81295, 81297, 81298, and 81317.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), expandable controller (E2377), power seat elevation feature (E2300) and Ottobock extremity support hand pad (K0108) for the enrollee.
You asked the Plan to pre-approve these services. You say that these items are medically necessary. The Plan denied your request. The Plan says that these items are not medically necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic connection, harness and expandable controller. Our Medical Director states that the documentation does not support that the expandable controller with harness and electronic connection were medically reasonable and necessary for the enrollee in this case. The documented upper limb strength was sufficient to be able to control the power options using their own switches which are included in the allowance of these power options. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage for an electronic connection, harness and expandable controller. Medicare rules say that a power seat elevation feature (E2300) is not covered because it is not primarily medical in nature. The Ottobock extremity support hand pad does not serve a purpose that is primarily medical in nature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), expandable controller (E2377), power seat elevation feature (E2300) and Ottobock extremity support hand pad (K0108) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 6, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 87640 billed for date of service March 1, 2023. 
 
You asked the Plan to pay for procedure code 87640. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says that this service is not supported for separate payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has indicated in the case file that medical records were 
provided to support this claim. However, no medical records were forwarded to us for review. Without the 
necessary records, we cannot verify the Plan's claim that this service was not separate and distinct from code 
87641, and therefore should not be billed separately. The Plan has not substantiated their denial in this case; the 
code at issue was reported with modifier 59 to bypass the edit. Therefore, we decided that the Plan has to pay 
for procedure code 87640 billed for date of service March 1, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 
billed for December 5, 2022, to December 27, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for 
the pneumatic compression device (PCD) coded E0675 billed for December 5, 2022, to December 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 14, 2022, to 
September 12, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider its 
denial. 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 July 15, 2022. The NOA was not received by the Plan until November 3, 
2022. 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 August 14, 2022, to September 12, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve SNF care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the requested SNF admission is not medically necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF care. Our Medical Director states that no required skilled nursing services are identified. The documentation supports that the enrollee may benefit from skilled therapy services. The documentation does not support that it was medically reasonable and necessary to provide skilled services on a daily basis in a skilled nursing facility setting. Our Medical Director found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for emergency room services and outpatient 
hospital observation on February 23, 2023, to February 25, 2023. 
 
You asked the Plan to waive the cost share for ER and outpatient hospital observation. You say that you want 
to appeal the amount being charged. 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 $50 
copayment for emergency care. Emergency care refers to services that are furnished by a provider qualified to 
furnish emergency services and needed to evaluate or stabilize an emergency medical condition. You must pay 
a 10% coinsurance for outpatient hospital observation.  and outpatient hospital observation. Observation 
services are hospital outpatient services given to determine if you need to be admitted as an inpatient or can be 
discharged. $50 copayment + $11.48 coinsurance = $61.48. Therefore, results in the total cost sharing amount 
of $61.48.  
 
You have been asked to pay a $50 copayment for ER and 10% coinsurance for outpatient hospital observation. 
This item/service falls within the emergency care and outpatient hospital observation 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 cost share for emergency room services and outpatient hospital observation 
on February 23, 2023, to February 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
You asked the Plan to pre-approve the dental services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plan's denial. The Plan requested a reopening and included claim documentation.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record shows your benefit for the requested item or service was exhausted on date of service February 3, 2023.
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded as 88341, 88342, 88360 and 88381 provided to the enrollee on March 1, 2022.
You asked the Plan to pay for the laboratory services. You say that the enrollee has been diagnosed with cancer and therefore, the enrollee's physician has ordered molecular testing as part of the treatment plan. The Plan denied your request. The Plan says that the sample was collected while the enrollee was inpatient. Maximus overturned the Plan's denial. The Plan requested a reopening and provided documentation to confirm the enrollee was an inpatient in the hospital when these services were provided. The Plan is correct in this case as Medicare rules say that carriers may not pay for the technical component of radiology services furnished to hospital patients. We looked at 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 the laboratory services coded as 88341, 88342, 88360 and 88381 provided to the enrollee on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 81345 provided on September 22, 2022.
You asked the Plan to pay for these services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that this is not covered.
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. This test is currently listed as not covered by Medicare in the DEX Diagnostic Exchange. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 81345 provided on September 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (PT) services received on January 12, 2023, 
to February 23, 2023. 
 
You asked the Plan to pay for the PT services. You say that the services were medically necessary for your 
condition. The Plan denied your request. The Plan says the services are not covered for your condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT services. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the documentation available for review did not include a description 
of previous treatment such as patient education, the use of medications or bite splints. There was not a relevant 
medical history or pertinent tests and procedures from the referring medical provider. There is no indication 
that you failed initial conservative treatment or that you would require referral for skilled outpatient 
rehabilitation. Additionally, you have previously been treated with outpatient therapies and should have 
received adequate education and treatment to allow for home care. The requested therapy services were not an 
appropriate duration and frequency for treatment of your medical condition and therefore were not 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 PT services have not been met. Therefore, we decided that the Plan does not 
have to pay for physical therapy (PT) services received on January 12, 2023, to February 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 2, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on November 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiology visit provided on January 11, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the OON cardiology visit. You say that the services provided were medically 
necessary and should be paid.  The Plan denied your request. The Plan says these services were routine, and no 
authorization for requested for OON care.  
 
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 the cardiology visit provided on January 11, 2023, 
by an out-of-network (OON) provider.