Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on December 01, 2022. 
 
You asked the Plan to pay for acupuncture services. 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 acupuncture services 
provided on December 01, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on September 
19, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on September 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the eye exam and the fundus photography provided on September 14, 2022.
You asked the Plan to waive the cost-sharing for the eye exam and the fundus photography. You say that these services have been covered in previous years. 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% coinsurance for annual diabetic retinopathy screening received out-of-network. You have been asked to pay a 50% coinsurance for the eye exam and the fundus photography. Your provider billed these services with a diagnosis of Type 2 diabetes indicating this was diabetic retinopathy screening.
This item/service falls within the annual diabetic retinopathy screening received out-of-network 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 eye exam and the fundus photography provided on September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150-XU, 87798-XU, and 87641-XU 
billed for date of service November 8, 2022. 
 
You asked the Plan to pay for procedure codes 87150-XU, 87798-XU, and 87641-XU. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the codes are not separately payable. 
 
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 87150 
is a column II code to column I code 87500. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -XU modifier is not supported as a separate and distinct procedural service.  
 
We have confirmed that codes 87798 and 87641 are column II codes to column I code 87801. This claim has 
not been billed with an appropriate modifier to bypass the edit. The -XU modifier is not supported as a separate 
and distinct procedural service. 
 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 87150-XU, 87798-XU, and 87641-XU billed for date of service 
November 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from October 28, 2021, to November 3, 2021, and billed under diagnosis related group (DRG) code 481.
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your request. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for acute inpatient hospital care billed at DRG 481 (Hip and femur procedures except major joint with comorbidity). The medical records show the enrollee was a then a 68-year-old woman with a medical history that included hypertension, GERD, and previous bariatric surgery, who suffered a displaced intertrochanteric fracture of the left femur. The enrollee underwent open reduction and internal fixation of the hip. The enrollee had acute blood loss anemia requiring transfusion of one unit of packed RBCs, and severe protein calorie malnutrition. On post-op day 1, PT noted that the enrollee ambulated 100 feet with a walker and minimal assistance. The assessment included diagnoses of hypokalemia likely related to HCTZ use, hyponatremia, chronic: mild, with a plan to monitor clinically. Based on the submitted documentation, the record supports the Plan's revised DRG of 482 (Hip and femur procedures expect major joint without comorbidity/major comorbidity).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee from October 28, 2021, to November 3, 2021, and billed under diagnosis related group (DRG) code 481.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion (eg, 
corn or callus) (11055) provided October 25, 2022. 
 
You asked the Plan to pay for the routine foot care. You say that you do not feel that you should have to pay 
due to the pain you were having at the time of the procedure. The Plan denied your request. The Plan says this 
service is not covered under the Plan benefits. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for the paring or 
cutting of benign hyperkeratotic lesion (eg, corn or callus) (11055) provided October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94760 for date of service July 6, 2022. 
 
You asked the Plan to pay for procedure code 94760. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not separately payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 94760 is noninvasive ear or pulse oximetry for oxygen 
saturation; single determination. 
 
We find that CPT code 94760 is not supported in the medical record. Specifically, this code has a status code of 
"T". Since there are other services payable under the physician fee schedule billed on the same date by the 
same provide, this means that these services are bundled into the physician services for which payment is 
made. Separate payment cannot be made as billed. Based on this information, we decided that Medicare rules 
for coverage of procedure code 94760 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 94760 for date of service July 6, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Clinical Brachytherapy Radiation Treatment (77778) and SBRT (77373) for the enrollee.
You asked the Plan to provide coverage for this treatment. You say that at the time of the appeal, this treatment was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Clinical Brachytherapy Radiation Treatment (77778) and SBRT (77373). The Maximus Physician Reviewer determined that combination external beam radiotherapy (SBRT) and brachytherapy along with neoadjuvant androgen deprivation is considered to be the standard of care for high risk localized prostate cancer. The health plan has requested a re-opening, citing an error on the face of the evidence. The health plan has stated that it disagrees with our consultant's determination. The plan states that the Maximus reviewer did not consider the Medicare guidelines found in LCD L35076 which states that SBRT is "indicated for patients with clinically localized, low- to intermediate-risk prostate cancer." This member has high risk prostate cancer. Further by reviewing the request based on reasonable and necessary criteria, the Maximus reviewer did not consider that SBRT is not the accepted standard of care and exceeds the need for this member with high-risk prostate cancer.
The medical records show the enrollee was a then 78-year-old man with a diagnosis of high-risk disease prostate cancer (Grade 4). For his high-risk prostate cancer, radiation treatment with combination brachytherapy was recommended, followed by SBRT to the prostate and pelvic lymph nodes. The Plan is correct in this case. LCD L35076 states that Stereotactic body radiation therapy (SBRT) is indicated for patients with clinically localized, low- to intermediate-risk prostate cancer. There is insufficient evidence in the medical literature to support the use of SBRT in the treatment of men with high-risk prostate cancer. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this treatment have not been met. Therefore, we decided that the Plan does not have to provide coverage for Clinical Brachytherapy Radiation Treatment (77778) and SBRT (77373) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for code 99153 billed for date of service April 12, 2022.
You asked the Plan to pay for code 99153. You say that these services were medically necessary. The Plan denied your request. The Plan says that this code has no physician work associated with it and is therefore a technical component only code.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 identifies technical component only stand-alone codes.
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for code 99153 billed for date of service April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (82948, 85052, 80053, 83735, 36415, 87340) and drugs (Q4081, J1644, J2270, J1642) provided from June 8, 2021, to June 9, 2021.
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 additional information regarding the errors on the claim. The Plan demonstrated that the claim shows this was submitted with bill type 127, and with condition code W2. As the claim met the conditions explained in the Medicare guidelines, the status indicator of Q4 for codes 36415, 80053, 82948, 83735, 85025 and 87340 changed to a status code indicator of "N".
A status code indicator of "N" is for services that are always packaged and cannot received separate payment. As all codes on the claim had a status indicator of "N", no payment could be made per the Medicare guidelines.
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, this claim could not be paid as billed due to issues with the status code indicator for the codes billed. 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 (82948, 85052, 80053, 83735, 36415, 87340) and drugs (Q4081, J1644, J2270, J1642) provided from June 8, 2021, to June 9, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 1, 2022.
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99231 billed for date of service 
March 18, 2022, to March 19, 2022. 
 
You asked the Plan to pay for procedure codes 99100 and 99231. You say that you disagree with the denial. 
The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable and code 99231 was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 99100 and 99231 have not been met.  
 
The Plan must follow Medicare rules. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue and the claim for code 99231 was not billed with the POS code 21. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 99100 and 99231 billed for date 
of service March 18, 2022, to March 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share applied to outpatient surgery and pacemaker insertion provided on July 20, 2022.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information on their review. The Plan says that upon our secondary review it was determined you appealed the 20% coinsurance charged for outpatient surgical supplies for the insertion of a cardiac pacemaker. The 20% coinsurance benefit for surgical supplies is clearly spelled out in the Plan contract. The Plan also provided a copy of the Explanation of Benefits showing the breakdown of each 20% coinsurance amount.
The Plan is correct. 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 cost share for each outpatient service provided, such as surgery and devices implanted during the surgery. 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 or reduce the cost share applied to outpatient surgery and pacemaker insertion provided on July 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from April 29, 2022, to May 28, 2022.
You asked the Plan to pay for the home health services as billed. You say that these services were medically necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. Maximus overturned the Plan's denial. The Plan requested a reopening and provided the NOA.
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a NOA must be submitted for the first period of care in 2022, using the first date of the period as the "admission" date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from April 29, 2022, to May 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening for the enrollee.
You asked the Plan to pre-approve the requested LDCT scan. You say that the requested service is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of the requested service. Maximus overturned the Plan's denial. The Plan requested a reopening stating that Maximus applied the criteria incorrectly.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter. We reviewed the file and the Medicare rules. We find that the enrollee does not have a tobacco smoking history of at least 20 pack-years or is a current smoker or former smoker who quit within the last 15 years. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gammagard (J1569).
You asked the Plan to pre-approve Gammagard. You say that you need this drug to keep your immune system as strong as possible and prevent you from going back into the hospital. The Plan denied your request. The Plan says that the requested drug is not medically necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Gammagard. Our Medical Director states that you do not have an indication for Gammagard that is supported in the compendia or in the medical literature. The documentation does not support that the Gammagard is safe and effective, and otherwise reasonable and necessary for you in this case. Our physician reviewer found that your condition does not meet criteria for coverage of Gammagard.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gammagard have not been met. Therefore, we decided that the Plan does not have to pre-approve Gammagard (J1569).