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

We decided that the Plan does not have to pre-approve Vertiflex Superion interspinous and/or interlaminar device (22869).
You asked the Plan to pre-approve the Vertiflex device. You say that the minimally invasive implantation of a posterior interspinous process spacer device is the most appropriate treatment and does meet requirements as being reasonable and medically necessary. The Plan denied your request. The Plan says medical studies have not proven that the device is helpful for treatment of the enrollee's health problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion interspinous and/or interlaminar device (22869).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating ambulatory facility on September 1, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you feel like you are being greatly overcharged. 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 $275 copayment for outpatient surgery/ambulatory surgical center. You have been asked to pay a $275 copayment for an outpatient surgery. The correct copayment has been applied to the services that were provided. The procedure that was performed is considered an outpatient surgery. An outpatient surgery falls within the outpatient surgery/ambulatory surgical center 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 outpatient surgery provided by a participating ambulatory facility on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (93948, 99496) provided on February 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an OON home visit. You say that this should not have required authorization. The Plan denied your request. The Plan says OON services require 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 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 home visit (93948, 99496) provided on February 24, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fora stress test provided on June 8, 2020 by an out of network (OON) provider.You asked the Plan to pay fora stress test. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there is no referring provider.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 fora stress test provided on June 8, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foreyewear provided on July 16, 2020.You asked the Plan to pay foreyewear. You say that you do not agree with the Plan's decision.The Plan denied your request. The Plan says the denial of payment for this item is correct, because the Plan paid the full $200 allowance for eyewear, soyou are responsible for any amount beyond this.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 routine eyewear up to $200 per year.We looked at the file and the Plan's rules. The Plan paid the full $200 eyewear allowance for 2020, so you are responsible for any charges beyond this.Therefore, we decided that the Plan does not have to pay foreyewear provided on July 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran esophagogastroduodenoscopy (43239) provided on September 29, 2020.You asked the Plan to waive the copayment foran esophagogastroduodenoscopy. You say that you believe this copayment should be lower.The Plan denied your request. The Plan says this processed 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 surgery, including endoscopies, provided at an outpatient hospital facility. You have been asked to pay a $350 copayment for an esophagogastroduodenoscopy provided at an outpatient hospital facility. 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 foran esophagogastroduodenoscopy (43239) provided on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on July 13, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were not examined and if you had known the test would cost $50, you never would have done it. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $50 copayment for urgently needed services. You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The medical record shows your temperature, oxygen saturation and heart rate were measured. Therefore, an examination was completed.
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 the urgent care visit provided on July 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Synvisc injection rendered on July 20, 2020.
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance was applied 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 20% coinsurance for Part B drugs obtained in a provider's office or outpatient setting.
Review of the file shows that you received a Synvisc injection on July 20, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the Part B drugs obtained in a provider's office or outpatient setting 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 coinsurance for the Synvisc injection rendered on July 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer device.
You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says this 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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that the spacer is experimental. More research is needed to show safety and efficacy of this device.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve a Superion interspinous spacer device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing you received.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that the routine physical checkup exclusion applies to (a) examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury; and (b) examinations required by third parties such as insurance companies, business establishments, or Government agencies. 

We looked at the file and Medicare rules.The requested COVID-19 testing was required by your work after a possible contact. Testing required by a third party is not covered by Medicare or your plan.Therefore, we decided that the Plan does not have to pay for the COVID-19 testing you received.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay for an office visit billed to the enrollee for January 23, 2020.

You asked the Plan to pay for this service. 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 administratively for a lack of information regarding the claim. The Plan requested a reopen and provided additional claim information. The Plan says that this claim denied because the use of  Modifier 25 does  not  support  the  Evaluation  and  Management code as a significant, separate service, warranting separate reimbursement. The Plan says that the medical records (pages 11 -12) show the enrollee was only seen for allergy testing/follow up and no other issues were addressed during the visit.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and submit medical records that support the services billed. In this case, the claim submitted is not supported by the medical records provided. The code submitted is not the appropriate code for the diagnosis reported. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for an office visit billed to the enrollee for January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a routine physical exam provided on 
August 12, 2020. 
 
You asked the Plan to waive the coinsurance for a routine physical exam. You say that you were not informed 
that the provider went out-of-network. 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 40% 
coinsurance for out-of-network routine physical exams.  
 
You received a routine physical exam on August 12, 2020, from an out-of-network provider. Therefore, you 
are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is 
$114.42 and 40% of that is $45.77.  
 
You have been asked to pay the total coinsurance amount of $45.77 for a routine physical exam. A routine 
physical exam falls within the routine physical exams 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 
coinsurance for a routine physical exam provided on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit (99211) provided on July 9, 2020. 
 
You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration because the 
right to recover for services provided to eligible beneficiaries is not extinguished by plan regulation.  The Plan 
denied your request. The Plan says this service was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that all charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus 
vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue 
code 0510. 
 
We find that CPT code 99211 is not supported in the record. Specifically, this claim has not been billed with 
the required revenue code. Based on this information, we decided that Medicare rules for coverage of the 
outpatient visit have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient 
visit (99211) provided on July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for vision care and ophthalmic biometry 
provided on October 6, 2020. 
 
You asked the Plan to waive the copayments for vision care and ophthalmic biometry. You say that you 
disagree with the charges because you only went to have a diabetic eye exam done. 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 $45 
copayment for eye exams to diagnose and treat diseases and conditions of the eye. Your contract with the Plan 
also clearly says that you must pay a $5 copayment for diagnostic procedures and tests.  
 
The medical records show that you received vision care to treat or diagnose a condition of the eye on October 
6, 2020. Therefore, you are responsible to pay the $45 copayment.  
 
The medical records also show that you received ophthalmic biometry on October 6, 2020. Therefore, you are 
responsible to pay the $5 copayment.  
 
The total amount you owe is: $50.  
 
You have been asked to pay the total copayment amount of $50 for vision care and ophthalmic biometry. 
Vision care falls within the vision care benefit category. Ophthalmic biometry 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 waive the 
copayments for vision care and ophthalmic biometry provided on October 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 29, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says Medicare denies coverage when a laboratory 
assays two or more genes in a patient in parallel. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) provided August 21, 2020. 
 
You asked the Plan to pay for the core build-up. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this service is only covered when performed with a crown. 
 
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 service is only covered 
when performed with a crown. The provided records do not show a crown being placed. Therefore, we decided 
that the Plan does not have to pay for a core build-up (D2950) provided August 21, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee 
from December 16, 2019 to December 23, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network 
physician services provided to the enrollee from December 16, 2019 to December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on September 23, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges 
because you only saw a physician's assistant, not a physician. 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 $45 
copayment for specialist visits.  
 
The medical records show that you had a specialist visit on September 23, 2020. Therefore, you are responsible 
to pay the $45 copayment.  
 
You have been asked to pay a $45 copayment for a specialist visit. A specialist 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 a specialist visit provided on September 23, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency care you received on 
January 10, 2020. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the cost share. 
 
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 $120 
copayment for emergency care.  
 
Review of the file shows that you were provided emergency services on January 10, 2020. You have been 
asked to pay a $120 copayment for the services. The services fall 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 the emergency care you received on January 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient laboratory services rendered 
on July 7, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you were not told the services 
would have a copayment. The Plan denied your request. The Plan says the copayment was applied 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 $30 
copayment for Medicare-covered lab services and diagnostic procedures/tests performed in an outpatient 
hospital facility.  
 
Review of the file shows that you received laboratory services on July 7, 2020. The Plan contract says that 
there is a $30 copayment for Medicare-covered lab services and diagnostic procedures/tests performed in an 
outpatient hospital facility. This cost sharing is a contractual obligation you agreed to pay when you enrolled in 
the Plan. However, the Medicare allowed amount for these services was $9.22. Given that the allowed amount 
was less than the $30 copayment, you have been asked to pay $9.22 for these services. 
 
Therefore, we decided that the Plan does not have to waive the copayment for the outpatient laboratory services 
rendered on July 7, 2020.