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

We decided that the Plan does not have to pay for laboratory services (87798 x 13, 87481 x 5, 87801 and 87801-59) provided to the enrollee on September 9, 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 for insufficient information in the case file. The Plan requested a reopen and submitted additional information.
The Plan noted that a test panel is a single test with multiple components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed as individual components although the test reports multiple individual pathogens and/or targets. Stacking of codes in unacceptable.
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, this claim could not be paid as billed due to the Medicare rules for unbundling these types of testing panels. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87798 x 13, 87481 x 5, 87801 and 87801-59) provided to the enrollee on September 9, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for services billed to the enrollee under codes 87150-59 x12, 87798-59 x13, 87481-59 x4, 87801-59 x2, 87640-59, and 87653-59, for January 14, 2023.
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 overtured the Plans denial for insufficient explanation of their denial. The Plan requested a reopen and provided additional information. The Plan noted that a test panel is a single test with multiple components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed as individual components although the test reports multiple individual pathogens and/or targets. Stacking of codes in unacceptable. Additionally, per the guidance in National Coverage Determination (NCD) 190.12, such panel testing is considered excessive testing and not medically necessary.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The diagnosis code reported was n39.0 for a urinary tract infection, site not specified. In this case, this claim could not be paid as billed due to the Medicare rules for unbundling urinary panels. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for services billed to the enrollee under codes 87150-59 x12, 87798-59 x13, 87481-59 x4, 87801-59 x2, 87640-59, and 87653-59, for January 14, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for community psychiatric supportive treatment provided from 
April 4, 2023, to June 15, 2023. 
 
You asked the Plan to pay for community psychiatric supportive treatment. You say that the services were 
medically necessary and should be covered. The Plan denied your request. The Plan says the services were 
rendered by a licensed professional counselor (LPC). An LPC is not a Medicare-qualified mental health care 
professional.  
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for community psychiatric supportive 
treatment provided from April 4, 2023, to June 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination provided on March 20, 2023. 
 
You asked the Plan to pay for a radiologic examination. You say that the services should be covered. 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 radiologic examination 
provided on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services provided on March 8, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the ultrasound services. You say that these services do not require authorization. 
The Plan denied your request. The Plan says the services were not authorized. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 ultrasound services provided on March 8, 
2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume 
assured pressure support (AVAPS) during sleep as an outpatient. The records do not show this has been tried as 
an outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with 
BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on May 16, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
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 $240 
copayment for outpatient surgery/Medicare-covered surgery atan ambulatory surgicalcenter. 
 
You have been asked to pay a $240 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-covered surgery atan ambulatory surgicalcenter 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 an outpatient surgery provided on May 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) 
scan provided on February 09, 2023. 
 
You asked the Plan to waive the copayment for the magnetic resonance imaging (MRI) scan. You say that you 
have never had to pay for this service in the past. 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 $150 
copayment for outpatient diagnostic tests and therapeutic services. 
 
You have been asked to pay a $150 copayment for the magnetic resonance imaging (MRI) scan. This 
item/service falls within the outpatient diagnostic tests and therapeutic 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) scan provided on February 
09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 02, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services should be covered. 
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 subsequent nursing 
facility care provided on June 02, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing, 22 or more drug classes (G0483) 
provided March 13, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that please kindly review the attached medical 
documents and reprocess this claim. The Plan denied your request. The Plan says an attachment and/or other 
documentation is required to adjudicate this claim. Missing patient medical record for this service. 
 
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 laboratory service have been met. 
Additional records were requested from the provider. The records show that the Plan made multiple attempts to 
obtain the needed records without success. Therefore, we decided that the Plan does not have to pay for the 
definitive drug testing, 22 or more drug classes (G0483) provided March 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80307) provided April 11, 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 medical records submitted do not include the order to support the code billed; 
therefore, the billed service cannot be verified.  
 
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 80307 is 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.  

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 there is no 
documentation to support procedure code 80307 provided April 11, 2023. Provided records in this case do not 
document an order for 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).  
 
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 the laboratory services (80307) provided April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 22, 2023, 
to May 29, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services should be covered. 
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 subsequent nursing 
facility care provided on May 22, 2023, to May 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive this cost share ($132.18) charged for specialist office
physician services provided on January 4, 2023.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct as you
were there less than 30 minutes. The Plan denied your request. The Plan says this cost sharing was charged
correctly based on the medical records showing the appointment exceeded 30 minutes. Maximus overturned the
Plans denial due to insufficient information in the case file. The Plan requested a reopen and provided
additional information.
The Plan is correct in this case. 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 10% coinsurance for specialist office physician services.
Based on the claim submitted by your provider, the medical records 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 this cost share ($132.18) charged for specialist office physician services provided on January 4, 2023.
Appeal type: Surgery
Decision: Partially Favorable

 We decided that the Plan has to pay for procedure codes C1713, C1776, 82947, 80048, 85027, 73560, 27447, 
64447, 97110, 97116, 97161, J0690, J2704, J1650, & 93005. We decided that the Plan does not have to pay 
for procedure code 97530.  
 
You asked the Plan to pay for outpatient services (C1713, C1776, 82947, 80048, 85027, 73560, 27447, 64447, 
97110, 97116, 97530, 97161, J0690, J2704, J1650, 93005) provided on March 10, 2023 to March 12, 2023. 
You say that the services were medically necessary. The Plan says that the claim cannot be paid as billed. 
 
We decided that the Plan has to pay for procedure codes C1713, C1776, 82947, 80048, 85027, 73560, 
27447, 64447, 97110, 97116, 97161, J0690, J2704, J1650, & 93005.  
 
"The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent 
efforts to gather and forward information to the Independent Review Entity (IRE). 
 
The plan did not provide any rationale for why these codes were denied and failed to cite a Medicare policy to 
support the denial of these services. Therefore, we decided that the Plan has to pay for procedure codes C1713, 
C1776, 82947, 80048, 85027, 73560, 27447, 64447, 97110, 97116, 97161, J0690, J2704, J1650, & 93005.  
 
We also decided that the Plan does not have to pay for procedure code 97530. 
 
The Plan follows Medicare rules. Medicare rules say that a GN, GO, or GP modifier is required for all claim 
lines reporting revenue codes 042X, 043X, or 044X. 
 
The file shows that code 97530 was reported with revenue code 0420 but was not billed with a required GN, 
GO, or GP modifier. Therefore, we decided that the Plan does not have to pay for procedure code 97530. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on March 27, 2023. 
 
You asked the Plan to pay for laboratory testing. You say that this was medically necessary and should be 
covered. 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 laboratory testing 
provided on March 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the orthotic device provided on June 12, 
2023. 
 
You asked the Plan to waive the coinsurance for the orthotic device. You say that you could have gotten this 
for cheaper online. 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 20% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for the orthotic device. This item/service falls within the 
prosthetic devices and related supplies 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. The total you owe is $100 ($500 allowed amount x 20% coinsurance = $100). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the orthotic device provided on 
June 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 31, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that you are an independent laboratory and did not 
interact directly with the enrollee. 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 genetic testing 
provided on May 31, 2023.