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

 
We decided that the Plan does not have to pay for the office visits (99213) and the psychotherapy (90833) 
rendered by the out of network (OON) provider from January 9, 2020 to July 23, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for the office visits (99213) and the psychotherapy (90833) rendered by the out of network 
(OON) provider from January 9, 2020 to July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99205), fundus photography (92250), 
fluorescein angiography (92235), and the electroretinography (ERG) (92273) rendered by the out of network 
(OON) provider on January 17, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for the office visit (99205), fundus photography (92250), fluorescein angiography 
(92235), and the electroretinography (ERG) (92273) rendered by the out of network (OON) provider on 
January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1833) provided on April 13, 2020. 
 
You asked the Plan to pay for the knee orthosis. You say that  The Plan denied your request. The Plan says the 
code in dispute is not supported by the records provided. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The medical records provided only show issues were addressed with sternum pain, muscular 
deconditioning, right shoulder pain, and thoracic spine pain. The clinical information provided did not record 
issues with the knee. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for a knee orthosis 
(L1833) provided on April 13, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for intubation (31500) provided on May 20, 2019. 
 
You asked the Plan to pay for the intubation. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that this claim was not submitted with an appropriate 
primary or first listed diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 31500 is supported in the record. Specifically, per Medicare, code R06.02 is a valid 
primary or first listed diagnosis code. Based on this information, we decided that Medicare rules for coverage 
of the intubation have been met. It is the burden of the Medicare Health Plan to substantiate the denial with 
evidence. The denial is not substantiated and we must find in your favor Therefore, we decided that the Plan 
has to pay for intubation (31500) provided on May 20, 2019.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the progressive lenses and scratch resistant coating 
provided on March 6, 2020. 
 
You asked the Plan to pre-approve these services. You say that you would like these additions to be 
reimbursed. The Plan denied your request. The Plan says that upgrades are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers the Medicare-covered standard frames and lenses for cataracts up to the Medicare 
allowed amount but does not cover any upgrades. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the progressive lenses and scratch resistant coating provided on March 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0367) and 
fixed partial denture sectioning (D9120) provided on May 29, 2020. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation and fixed partial denture sectioning. 
You say that the Plan says it covers comprehensive dental services in addition to preventive services. You also 
say that you believe this work falls within the comprehensive dental services that are covered. The Plan denied 
your request. The Plan says these services are not covered benefits under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam CT capture and interpretation (D0367) and fixed partial denture sectioning (D9120) provided on May 29, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ER visit provided on March 22, 2020. 
 
You asked the Plan to waive the copayment for an ER visit. You say that the copayment is a financial hardship 
and you feel that that you should not have to pay it since you had to be returned to the emergency room after a 
previous discharge. The Plan denied your request. The Plan says the claims were processed correctly and you 
are being charged the correct amount. 
 
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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency care 
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 ER visit provided on March 
22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a visual field exam (92083) performed on 
March 15, 2020. 
 
You asked the Plan to waive the copayment for a visual field exam. You say that the copayment should be 
waived. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 $45 
copayment for each specialist in-person office visit.  
 
You have been asked to pay a $45 copayment for a visual field exam. A visual field exam falls within the 
"Physician/Practitioner services, including doctor's 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 copayment for a visual field exam (92083) performed on March 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health care provided on 
March 5, 2020. 
 
You asked the Plan to waive the copayment for outpatient mental health care. You say that you disagree with 
the charges because the service is required for you to receive your medication. The Plan denied your request. 
The Plan says the claims were processed correctly, and you are being charged the correct amount. 
 
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 $30 
copayment for outpatient mental health care provided in a specialist's office.  
 
You have been asked to pay a $30 copayment for outpatient mental health care. Outpatient mental health care 
falls within the outpatient mental health care 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 outpatient mental health care provided on March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction provided on May 30, 2018 by an OON 
provider. 
 
You asked the Plan to pay for the extraction. You say that you were in severe pain, and needed a tooth 
extracted. You also say that this was an emergency service. The Plan denied your request. The Plan says this 
service was rendered by an OON provider. The Plan also says that you must use network providers to receive 
dental services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
extraction provided on May 30, 2018 by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the moderate sedation services provided during a central venous 
catheter placement on January 3, 2020. 
 
You asked the Plan to pay for the moderate sedation services. You say that this should be paid. The Plan denied 
your request. The Plan says that there is no evidence that an independent observer was present in the OR. 
 
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 99152 is Moderate sedation services provided by the same physician or other qualified health care 
professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence 
of an independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. 
 
We find that CPT code 99152 is supported in the medical record. Specifically, there is evidence that both a 
nurse practitioner and radiology technologist were present during the procedure and able to monitor patient 
status described in the code. Based on this information, we decided that Medicare rules for coverage of the 
moderate sedation services have been met. Therefore, we decided that the Plan has to pay for the moderate 
sedation services provided during a central venous catheter placement on January 3, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the CA 15-3 tumor antigen testing provided on March 4, 
2020. 
 
You asked the Plan to hold you harmless for the tumor antigen testing. You say that you were referred by your 
PCP to see these providers due to a lump that was suspicious for cancer. You had this testing ordered by one of 
the doctors at the cancer center and you were not told this was experimental and would not be covered. The 
Plan denied your request. The Plan says that this test is experimental and cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. This case was auto-forwarded to Maximus since the Plan missed the 60-day time 
frame to make its decision on the appeal. The case file submitted does not include information regarding the 
network status of the provider by whom this testing was ordered. In fact, the documentation does not 
definitively show the ordering provider. As there is no evidence that the ordering provider is out of network 
and there is no evidence that you were informed this testing would be noncovered, we find that the testing is 
considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the CA 15-3 
tumor antigen testing provided on March 4, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure, on one or more areas, each lasting 15 
minutes (97110) provided December 2, 2019 to December 20, 2019. 
 
You asked the Plan to pay for the therapeutic procedure. You say that you have attached supporting 
documentation. Please thoroughly review and reprocess the claim accordingly. The Plan denied your request. 
The Plan says there is insufficient documentation to corroborate the services to confirm Medicare coverage has 
been met. 
 
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 97110-GO-KX (7 units) and 97110-GP-KX (2 units) is 
therapeutic procedure, on one or more areas, each lasting 15 minutes. 
 
We find that CPT code 97110-GO-KX (7 units) 97110-GP-KX (2 units) is not supported in the medical record. 
Specifically, the documentation submitted did not include documentation of therapeutic procedure, 1 or more 
areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and 
flexibility. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure 
have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic procedure, on one 
or more areas, each lasting 15 minutes (97110) provided December 2, 2019 to December 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (CPT Code 
A0998) provided on February 27, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the member was not actually transported by ambulance. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 27, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(CPT Code A0998) provided on February 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hepatitis A vaccine and administration provided on 
October 15, 2019. 
 
You asked the Plan to pay for the Hepatitis A vaccine and administration. You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the Hepatitis A vaccine preventative immunization is not 
covered by Medicare. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Hepatitis A 
vaccine. The Plan follows the same rules.  
 
Records do not show that the enrollee has been directly exposed to any illness related to the Hepatitis A 
vaccine. Therefore, we decided that the Plan does not have to pay for the Hepatitis A vaccine and 
administration provided on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services provided on January 20, 2020. 
 
You asked the Plan to pay for the moderate sedation services. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says they have insufficient documentation to corroborate the 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. 
 
In this case, the CPT Code Manual definition of code 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not show who 
gave moderate sedation, how much was given, or when it was given. Based on this information, we decided 
that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided 
that the Plan does not have to pay for moderate sedation services provided on January 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share charged for inpatient care provided from 
January 3, 2020 to January 6, 2020. 
 
You asked the Plan to reduce this copayment. You say that you spent the first night in the emergency room and 
the next two nights as an inpatient. You state you should only have to pay for two nights as an inpatient. The 
Plan denied your request. The Plan says this copayment was charged based on the claim submitted by your 
provider and the Plan contract agreement. 
 
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 $450 per 
day for days 1 to 4 of an inpatient stay. Based on the records provided your status was converted from 
emergency room to an inpatient level of care on January 3, 2020. While you may have had to wait in the 
emergency room overnight until you could be placed onto the inpatient floor, your status was considered 
inpatient and continued over three midnights. Therefore, 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 cost share charged for 
inpatient care provided from January 3, 2020 to January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided on 
February 11, 2020. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being 
charged the correct amount. 
 
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 $60 
copayment for urgently needed services.  
 
You have been asked to pay a $60 copayment for urgently needed services. Urgently needed services fall 
within the urgently needed 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 
urgently needed services provided on February 11, 2020.