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

We decided that the Plan does not have to pay for the emergency department visit coded 99282 provided on September 13, 2020.
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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, the CPT Code Manual definition of code 99282 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low 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 presenting problem(s) are of low to moderate severity. We find that CPT code 99282 is not supported in the medical record. Specifically, this claim must be billed with a revenue code of 0510 and a type of bill of 13X. The claim was not submitted with these details. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99282 provided on September 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection provided by a participating provider on June 26, 2020.You asked the Plan to waive the copayment for an outpatient surgery. You say that you were prepared to pay $100, not $600. The Plan denied your request. The Plan says the correct copayment has been 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 $600 copayment for outpatient surgery/in-network. You have been asked to pay a $600 copayment for an outpatient surgery. The injection you received falls within the outpatient surgery/in-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 copayment for an injection provided by a participating provider on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on November 24, 
2020. 
 
You asked the Plan to pay for the first intraoral periapical x-ray. You say that you do not understand why the 
Plan did not pay for this x-ray. The Plan denied your request. The Plan says this service is not covered. 
 
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. Bitewing x-rays are the only x-rays covered under your plan. 
Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on 
November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retreatment of previous root canal therapy (D3347) 
provided on July 2, 2020. 
 
You asked the Plan to pay for the retreatment of previous root canal therapy. You say that you were advised 
that this service would be covered at 50%. The Plan denied your request. The Plan says this service is not a 
covered benefit 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 
retreatment of previous root canal therapy (D3347) provided on July 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe aspiration and/or injection of large joint or joint capsule (20610) provided on September 15, 2020.You asked the Plan to waive the copayment forthe aspiration and/or injection of large joint or joint capsule. You say that this bill is not consistent with previous billings.The Plan denied your request. The Plan says the copayment processed correctly in this case.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 copayment for Medicare-covered surgery. You have been asked to pay a total cost share of $252.64 for the aspiration and/or injection of large join or joint capsule which is less than the required copayment of $395. This service provided falls within the Medicare-covered surgery 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 whenyou enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe aspiration and/or injection of large joint or joint capsule (20610) provided on September 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 14, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that you were under the impression you were in-
network. The Plan denied your request. The Plan says there was no authorization on file for these services. 
 
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 had network providers available 
who could have provided 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 medical services provided on August 14, 2020 by an out of network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor supply allowance (K0553) 
billed for date of service August 17, 2020. 
 
You asked the Plan to pay for the continuous glucose monitor supplies. You say that the medical records 
submitted support the items in dispute. The Plan denied your request. The Plan says the billed services were not 
supported. 
 
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 a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for a continuous glucose monitor supply allowance (K0553) billed for date of 
service August 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient diagnostic testing provided on October 5, 2020.You asked the Plan to waive the copayment forthe outpatient diagnostic testing. You say that you never had to pay this much before.The Plan denied your request. The Plan says you were charged the copaymentscorrectly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for Outpatient Diagnostic Tests and 20% coinsurance for medical supplies.You have been asked to pay a $150 copayment for the SPECT studies and $69.37 for the stress test. The myocardial SPECT studies and stress test fallwithin 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 forthe outpatient diagnostic testing provided on October 5, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay forthe services you received in the emergency department on September 21, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says that this is not a covered service.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.You were providedthe services by a contract provider. The file does not show that the Plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the Plan.Therefore, we decided that the Plan has to pay forthe services you received in the emergency department on September 21, 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 forthe medical services provided on February 11, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe services provided. You say that it is not possible to request authorization before services are rendered.The Plan denied your request. The Plan says the enrollee's health plan requires the utilization of network providers, and authorization for certain services.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 did not pre-approve the servicesat 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 forthe medical services provided on February 11, 2020, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe post stabilization care provided on September 19, 2020, through September 22, 2020.You asked the Plan to pay forthe post stabilization care. You say that you would like reconsideration because the post stabilization care was medically necessary.The Plan denied your request. The Plan says the medical records demonstrate the enrollee's emergency medical condition was stabilized by 3:06 p.m. on September 21, 2020.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 pay for the post stabilization care. Our reviewer says that as of 3:06 p.m.on September 21, 2020, the enrollee was hemodynamically stable for ambulance transport with monitoring to a Plan facility for observation/admission services. Our physician reviewer found the treating physician did not document in the physician notes, on a form,or in an order that the member was not stable for transfer on any dates of service.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 post stabilization care have not been met.Therefore, we decided that the Plan does not have to pay forthe post stabilization care provided on September 19, 2020, through September 22, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because the 
services rendered were medically necessary. The Plan denied your request. The Plan says the services were not 
urgent, emergent or approved in advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to pay forthe Fluid Circulating Cold Pad (E0218) purchased on June 5, 2020.You asked the Plan to pay forthis equipment. You say that this equipment was medically necessary. The Plan denied your request. The Plan says this equipment is not covered by Medicare. Maximus overturned the Plans denial as Plan directed care. The Plan requested a reopen and confirmed both you and the ordering provider were aware of the denial for coverage before you purchased the equipment. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules state a fluid circulating cold pad (E0218) will be denied coverage under Medicare. The Plan provided records to show that you and the provider were made aware of this prior to your receiving the equipment. Therefore, we decided that the Plan does not have to pay forthe Fluid Circulating Cold Pad (E0218) purchased on June 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on August 31, 2020. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration because this service 
should be covered as the office visit was necessary to determine the care that was needed. The Plan denied your 
request. The Plan says chiropractic care is only covered when it's manual manipulation of the spine consistent 
with Medicare coverage guidelines. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on September 24, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that this provider is in-network. The Plan says that 
prior authorization was not obtained. The Plan denied your request. The Plan says prior authorization was not 
obtained. The Plan says that the rendering facility is also out-of-network. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services provided on September 24, 
2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta 32 mg vial. 
 
You asked the Plan to pre-approve Zilretta. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says that this drug is not medically necessary for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that the 
service is medically reasonable and necessary. Our physician reviewer found the enrollee is a 70 year old 
female with a history of bilateral primary osteoarthritis of the knees. Based on the drug's label, it does not 
preclude use of the drug more than one time. In addition, based on the regulation 50.4.1 - Approved Use of 
Drug, Drugs or biologicals approved for marketing by the Food and Drug Administration (FDA) are considered 
safe and effective for purposes of this requirement when used for indications specified on the labeling. The 
documentation supports that Zilretta is medically reasonable and necessary for the patient and is safe and 
effective for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have been met. Therefore, we decided that the Plan has to pre-approve 
Zilretta 32 mg vial.  
 
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 waive the copayment for subsequent annual wellness visits (G0439) 
outpatient office visit (99214) provided June 22, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you went for a wellness visit and 
never had to pay any copayment previously. This was a wellness visit and nothing else. The Plan denied your 
request. The Plan says the correct copayment was applied per the Evidence of coverage. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 for 
Medicare covered physician services.  
 
You have been asked to pay $10 for the office visit. The office visit 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 subsequent annual wellness visits (G0439) outpatient office visit (99214) provided June 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on September 5, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for radiology services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for radiology services provided on September 5, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99222) provided on May 15, 2019. 
 
You asked the Plan to pay for hospital care. You say that you did not receive information about the enrollee's 
benefits in time. The Plan denied your request. The Plan says this claim was filed more than a year after the 
date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for hospital care was not filed until September 24, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for hospital care (99222) provided on May 15, 2019.