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

 
We decided that the Plan does not have to reduce the copayment for the laboratory services provided on 
September 27, 2023. 
 
You asked the Plan to reduce the copayment for the laboratory services. You say that you had only been charge 
a $10 copayment for lab services 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 $35 
copayment for out-of-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $35 copayment for the laboratory services. This item/service falls within the out-of-network outpatient diagnostic tests and therapeutic services and 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. Therefore, we decided that the Plan 
does not have to reduce the copayment for the laboratory services provided on September 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace provided on July 20, 2023. 
 
You asked the Plan to pay for the back brace. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says suppliers are prohibited from direct solicitation to 
Medicare beneficiaries. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact 
by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the back brace have 
not been met. Therefore, we decided that the Plan does not have to pay for the back brace provided on July 20, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 31, 2023, billed with 
procedure code 00812-QX-QS. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim is billed with an invalid principal 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that the reason for the encounter should be sequenced 
first and the appropriate personal and/or family history code(s) should be assigned as additional diagnos(es). 
 We looked at the file and Medicare rules. This claim is billed with principal diagnosis code Z80.0, described as 
family history of malignant neoplasm of digestive organs, which is an inappropriate principal diagnosis. Based 
on this information, we decided that Medicare rules for coverage of the practitioner services provided have not 
been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on July 
31, 2023, billed with procedure code 00812-QX-QS.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a permanent implantable defibrillator system
for the enrollee.

You asked the Plan to provide coverage for this device. The Plan denied your request. The Plan says the
Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and
stated that Maximus did not apply the correct criteria. The Plan noted that NCD 20.4 states enrollees must
not have supraventricular tachycardia such as atrial fibrillation with a poorly controlled ventricular rate. The
medical records show, and the Maximus physician reviewer pointed out that the enrollee has HFrEF
(LVEF:25-30%) and evidence of supraventricular tachycardia documented on a heart monitoring study.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for this device. Based on the medical records provided and confirmation in our previous review, the required
criteria are not met. Therefore, we decided that the Plan does not have to provide coverage for a permanent
implantable defibrillator system for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 25210 rendered on July 24, 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 services are not supported without the required documentation. 
 
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 25210 is "Carpectomy; 1 bone." 
 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 the procedure details cite at the 
dorsal margin of the abductor pollicis longus tendon, the joint capsule was incised and was able to being 
exposing the trapezium. There were findings of significant fibrosis about the CMC joint. The trapezium was 
able to be released. The trapezium was manipulated and released of the capsular tissue and ligamentous 
attachments. The trapezium and the heterotopic bone were removed. The STT joint was exposed, and using a 
7mm saw blade, the proximal surface of the trapezoid and the distal surface of the scaphoid were resected. The 
performed joint capsule was exposed/incised (along with the bony excisions) as part of the primary procedure 
and  not as separate procedure(s). Therefore, the documentation does not support CPT 25210: carpectomy, 1 
bone as a separate and distinct procedure from CPT 25447: arthroplasty, interposition, intercarpal or 
carpometacarpal joints. 
 
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 procedure code 25210 rendered on July 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on September 05, 2023. 
 
You asked the Plan to pay for the outpatient visit. You say that you cannot afford to pay for these services that 
you need. 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 outpatient visit 
provided on September 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 6, 2023. 
 
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 September 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798, 87471) provided on August 22, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87798, & 87471 are not supported in the medical record. Specifically, lab results were 
not provided for this service. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87798, 
87471) provided on August 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an oral device provided on July 13, 2023. 
 
You asked the Plan to reduce the coinsurance for an oral device. You say that you do not feel you owe this 
money as it is medically necessary. 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 durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for an oral device. This item/service falls within the durable 
medical equipment (DME) 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 $145 ($725 x 20% = $145). Therefore, we 
decided that the Plan does not have to reduce the coinsurance for an oral device provided on July 13, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant360 test (0326U) provided on August 3, 2023. 
 
You asked the Plan to pay for the Guardant360 test. You say that this test was ordered by an in-network 
provider. The Plan denied your request. The Plan says that this test is not covered because it was provided out-
of-network. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the Guardant360 test by a contract provider. The file does not show that the plan 
provided notice that the Guardant360 test would not be covered. Under Medicare rules, this means the 
Guardant360 test is considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
Guardant360 test (0326U) provided on August 3, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) (78815). 
 
You asked the Plan to pre-approve the PET scan. You say that this enrollee has a history of cancer and will 
benefit from this scan. The Plan denied your request. The Plan says the requested imaging is not medically 
necessary in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 the PET scan. Our physician reviewer 
found the magnetic resonance imaging (MRI) pelvis performed showing low intensity tract extending from the 
anus into the ischial and fossa on the right side close to the skin surface of gluteal fold consistent with fissure. 
A PET scan in an area of inflammation would not provide additional clinical information. There is no clinical 
documentation from a provider of why a PET scan is needed at this point. 
 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 the positron emission tomography (PET) with concurrently acquired computed 
tomography (CT) (78815).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunohistochemistry services provided to the enrollee
on December 16, 2022, billed with diagnosis codes C43.59 and C44.619.

You asked the Plan to pay for these services. The Plan denied your request. The Plan says these diagnosis
codes cannot be reported together. Maximus overturned the Plans denial. The Plan requested a reopen and
stated that Maximus did not apply the correct criteria. The Plan noted that this claim denied because this
service was billed with an inappropriate diagnosis code. The billed service has been denied because it was
reported with one or more diagnosis code pairs that are subject to an "Excludes1" note. An Excludes1 indicates
that the two conditions cannot occur together, such as a congenital form versus an acquired form of the same
condition.

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, we have confirmed that the reported codes cannot be billed together. The
ICD-10-CM Tabular List of Diseases and Injuries shows "C44" defined as "Other and unspecified malignant
neoplasm of skin Includes: malignant neoplasm of sebaceous glands malignant neoplasm of sweat glands" and
its expanded codes has an Excludes 1 "C43" for malignant melanoma of skin and its expanded codes.
Therefore, Codes C44.619 and C43.59 would not be billed together. Therefore, we decided that the Plan does
not have to pay for the immunohistochemistry services provided to the enrollee on December 16, 2022, billed
with diagnosis codes C43.59 and C44.619.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the device evaluation and the specialist 
services provided on June 29, 2023. 
 
You asked the Plan to waive the cost share for the device evaluation and the specialist services. You say that 
these services should be fully covered as preventative services. 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. Your 
contract with the Plan says that there is a $400 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. Your contract with the Plan also clearly says that you must pay a $25 
copayment for each visit to a specialist. 
 
You have also been asked to pay $33.75 towards the deductible for the device evaluation. The item or service 
you asked the Plan to waive the cost share for falls within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $400 deductible which applies to outpatient diagnostic tests and therapeutic services and 
supplies. This cost sharing is a contractual obligation that had not been met at the time the device evaluation 
and the specialist services was received on June 29, 2023.  
 
You have also been asked to pay a $25 copayment for the specialist services. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 the device evaluation and the specialist services provided on June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87798-59 x10 units, 87481-59 x2 
units, 87653-59, 87641-59) provided August 18, 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 87798-59 x10 units, 87481-59 x2 units, 87653-59, 87641-59 is a 
column II code to column I code 87801; however, 87798-59 x10 units, 87481-59 x2 units, 87653-59, 87641-59 
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 87798, 
the provider reported procedure code with appended modifier 59 distinct procedural service to bypass NCCI 
Edit with an infectious agent detection panel code. The documentation submitted was reviewed and does not 
meet criteria. The laboratory report does not include documentation to support rationale of separate billing, and 
therefore, cannot be verified. For code 87481, the provider reported procedure code with appended modifier 59 
distinct procedural service to bypass NCCI Edit with an infectious agent detection panel code. The 
documentation submitted was reviewed and does not meet criteria. The laboratory report does not include 
documentation to support rationale of separate billing, and therefore, cannot be verified. For code 87653, the 
provider reported procedure code with appended modifier 59 distinct procedural service to bypass NCCI Edit 
with an infectious agent detection panel code. The documentation submitted was reviewed and does not meet 
criteria. The laboratory report does not include documentation to support rationale of separate billing, and 
therefore, cannot be verified. For code 87641, the provider reported procedure code with appended modifier 59 
distinct procedural service to bypass NCCI Edit with an infectious agent detection panel code. The 
documentation submitted was reviewed and does not meet criteria. The laboratory report does not include 
documentation to support rationale of separate billing, 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 the laboratory services (87798-59 x10 units, 87481-59 x2 units, 87653-59, 87641-59) 
provided August 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a pelvic computed tomography (CT) scan 
provided on September 29, 2023. 
 
You asked the Plan to reduce the copayment for a pelvic computed tomography (CT) scan. You say that you 
have two insurances, you should not have to pay a copayment that is this high. 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 $200 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $200 copayment for a pelvic computed tomography (CT) scan. This item/service 
falls within the outpatient diagnostic tests and therapeutic services and 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. Therefore, we decided that the Plan 
does not have to reduce the copayment for a pelvic computed tomography (CT) scan provided on September 
29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (procedure code 99222) rendered on May 31, 
2022. 
 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 Current Procedural Terminology (CPT) code 99222 remains 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. 
 
In this case, the CPT Code Manual definition of code 99222 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit." 
 
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 the documentation do not support 
a comprehensive history and examination or complexity of medical decision making to justify this level of 
billing. 
 
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 hospital care (procedure code 99222) rendered on May 31, 2022.