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

We decided that the Plan does not have to pay for the genetic testing provided on February 5, 2023, billed with codes 81225, 81226, 81227 ,81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335 and 81479.

You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is supported in the medical record. 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 February 5, 2023, billed with codes 81225, 81226, 81227 ,81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335 and 81479.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound scan of the abdominal aorta (76706) provided
on August 25, 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 noted this claim denied because this service was billed with an inappropriate
diagnosis code. This claim was billed with diagnosis Z13.6, encounter for screening for cardiovascular
disorders. This is not an appropriate diagnosis code for "Ultrasound screening exam of abdominal aorta". There
is a more appropriate Medicare code for these services.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, there is a
discrepancy between the diagnosis code billed and the procedure code billed. Medicare rules for coverage of
these services have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound
scan of the abdominal aorta (76706) provided on August 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided the Plan does not have to pay for a compound drug (J7999) provided on October 26, 2022.
You asked the Plan to pay this claim. You say that this drug should be paid. The Plan denied your request. The
Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a
reopen and provided additional information. The Plan noted that these services were not payable because the
provider did not bill with the appropriate modifier. The Plan notes the claim was billed without the KD
modifier required by Medicare which shows as drug or biological infused through durable medical equipment.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code and when necessary, the
appropriate modifier. The Plan has provided a copy of the claim which shows the KD modifier was not billed.
Medicare coverage criteria were not met. Therefore, we decided that the Plan does not have to pay for a
compound drug (J7999) provided to the enrollee on October 26, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for hip x-rays (73502) provided on September 25, 2022, and October 11, 
2022, at the in-network benefit level. 
 
You asked the Plan to pay for the OON hip x-rays at the in-network benefit level. You say that you went to 
urgent care in another state, and they found that you had a hip fracture. You say that you were put in a 
wheelchair, taken to the emergency room, and were then hospitalized. You say that the services provided were 
urgent/emergent and should be paid as in-network. The Plan denied your request. The Plan says that there were 
services provided after the enrollee was stabilized and those remain out-of-network according to the benefits in 
the Evidence of Coverage.  
 
The Plan must follow Medicare rules. Medicare says that plans must pay for emergency and urgently needed 
services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, 
urgently needed care, renal dialysis, and pre-approved care. The Plan contract also says that cost-sharing for 
necessary emergency or urgently needed services furnished out-of-network is the same as for such services 
furnished in-network. The rules also 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 did not provide any rationale to support why these hip x-
rays were not considered urgently needed when they were clearly related to the other urgently needed care. 
Therefore, we decided that the Plan has to pay for hip x-rays (73502) provided on September 25, 2022, and 
October 11, 2022, at the in-network benefit level.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from July 28, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from July 28, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from July 28, 
2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of July 28, 2023, forward. Our physician reviewer found as 
of the last covered day, there is no indication in the available medical records that the enrollees psychiatric 
symptoms could not be managed on a less restrictive basis. As of the last covered day the enrollee did not 
express any active suicidal ideation or intent, or any intent to harm themselves or anyone else. The enrollee was 
not exhibiting any other significant symptoms such as psychosis or mania. The enrollee had no acute 
psychiatric issues that would require continued inpatient care beyond July 28, 2023. The enrollee has chronic 
symptoms. The available medical records do not support that continued inpatient care will change these 
symptoms or the enrollees current condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from July 28, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from July 28, 2023, 
forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the specialist office visit and
triamcinolone injection provided on November 2, 2022.
You asked the Plan to waive the cost-sharing for the specialist office visit and triamcinolone injection. You say
that there was an error with this claim, and you need reimbursement. The Plan denied your request. The Plan
says this cost sharing was charged correctly. Maximus partially overturned the Plan's denial. The Plan
requested a reopening and stated that Maximus did not apply the correct criteria.
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 Physician/Practitioner services in a specialist office and a 20% coinsurance for Medicare Part B
prescription drugs.
You have been asked to pay a $50 copayment the specialist office visit and a 20% coinsurance for the
triamcinolone injection. This specialist office visit falls within the Physician/Practitioner services in a specialist
office and the triamcinolone injection falls within the Medicare Part B prescription drugs 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-sharing for the specialist office visit and triamcinolone injection
provided on November 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for code J3490 provided to the enrollee on September 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 partially overturned the Plans
denial. The Plan requested a reopen and provided proof of payment for codes 64636, 64635, and J3301.
Regarding code J3490. The Plan follows Medicare rules. Medicare rules say that providers must report services
correctly. Providers must report services with the appropriate code. We find that CPT code J3490 is not
supported in the medical record. Specifically, this code was billed within the global surgery period of a surgery
procedure. Without an appropriate modifier, this code is not payable as billed. We looked at the file and
Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services
described by procedure code J3490 have not been met. Therefore, we decided that the Plan does not have to
pay for the services described by procedure code J3490 provided to the enrollee on September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on October 5, 2022.
You asked the Plan to pay for the office visit. You say that the service should be covered. The Plan denied your
request. The Plan says that the claim must be submitted to your primary insurance first.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has informed the
provider to submit the claim to the enrollee's primary insurance. As the secondary insurer, the Plan cannot be
held responsible for the office visit until the primary insurer has denied the claim for these services. Therefore,
we decided that the Plan does not have to pay for the office visit (99214) provided on October 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chair portion of a seat lift mechanism (A9270). 
 
You asked the Plan to pre-approve a chair. You say that you do not understand why you are unable to get a lift 
chair that you were approved for previously. The Plan denied your request. The Plan says this item is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that chairs are not a covered benefit.  
 
While a chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a chair portion of a seat lift mechanism 
(A9270).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on March 2, 2023. 
 
You asked the Plan to waive the copayment for an MRI. You say that you do not understand why you received 
a bill and are unable to afford the copayment due to your low income. 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 $350 
copayment for outpatient diagnostic radiology services.  
 
You have been asked to pay a $350 copayment for an MRI. This item/service falls within the outpatient 
diagnostic tests 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 MRI provided on March 
2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrodesis (22551), insertion of interbody 
biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring 
(eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, 
each interspace (List separately in addition to code for primary procedure) (22853), and  the allograft (20930). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says your doctor's notes do not show that your special imaging magnetic 
resonance imaging [MRI) showed a certain condition (significant spinal cord or nerve root impingement at the 
C5-6 level); therefore, this surgery is not medically necessary. 
 
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 pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of a three (3) month recent trial and failure of physical therapy. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the arthrodesis (22551), insertion of interbody biomechanical device(s) (eg, synthetic cage, 
mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to 
intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition 
to code for primary procedure) (22853), and  the allograft (20930).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of skin lesions (code 17110).  
 
You asked the Plan to pre-approve removal of skin lesions (code 17110). You say that removal of skin lesions 
is medically necessary. The Plan denied your request. The Plan says removal of skin lesions does not meet the 
Medicare LCD coverage criteria as the skin lesions are benign.  
 
The Plan follows Medicare rules. Medicare rules say that removal of skin lesions is covered when the criteria 
listed in the Medicare rules section of this decision are met.  
 
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 removal of skin lesions (code 17110). 
Our reviewer says that removal of skin lesions is not considered medically necessary. Our physician reviewer 
found the skin lesions represent cosmetic rather than medical significance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of removal of skin lesions (code 17110) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve removal of skin lesions (code 17110).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
the enrollee does meet all the requirements for a group 3 power wheelchair with tilt. The Plan denied your 
request. The Plan says that although there are three approved power options on this wheelchair (tilt, recline and 
elevating leg rests), there is not a medical need to control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee is non-ambulatory and requires a power 
wheelchair for mobility and performing her basic daily activities. The enrollee cannot perform pressure relief 
independently due to upper extremity weakness and requires a power wheelchair with power tilt and recline for 
adequate pressure relief and positioning. Our reviewer found that the enrollee requires power elevating leg rests 
for positioning of their lower extremities and lower extremity spasticity and edema. The complexity of their 
seating and positioning needs necessitates a more complex group 3 power wheelchair base. The expandable 
controller with harness and electronic connection are necessary to operate the group 3 power wheelchair base 
and the three power options via a joystick. Our physician reviewer also found that these components are 
required to operate 3 or more power options on a group 3 power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
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) billed with code 
E0675 for January 16, 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 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) billed with code E0675 for January 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Transcutaneous Electrical Never Stimulators (TENS) unit
supplies provided to the enrollee on September 29, 2022.
You asked the Plan to pay for the TENS unit supplies. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says that the provide billed the Plan for the rental of
a TENS unit. Maximus overturned the Plan's denial for insufficient information in the case file. The Plan
requested a reopen and noted the claim history shows this provider has been submitting claims for the TENS
unit (E0730 RR KX) indicating this is a rental item. Per Medicare guidelines, during the rental of a TENS unit,
supplies for the unit are included in the rental allowance. There is no additional allowance for items such as
electrodes, lead wires, and batteries. As the provider is renting the unit to the enrollee, the provider should not
bill for supplies separately based on the Medicare billing guidelines. Therefore, this claim was denied correctly.
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, the provider is billing for supplies separately for rented equipment, which
is not allowed. Medicare rules for payment of this claim are not met. Therefore, we decided that the Plan does
not have to pay for the Transcutaneous Electrical Never Stimulators (TENS) unit supplies provided to the
enrollee on September 29, 2022.