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

 
We decided that the Plan does not have to pay for the medical services provided on November 22, 2019 to 
December 14, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services should be covered under the 
facility's authorization. The Plan denied your request. The Plan says the facility services weren't authorized 
either. The Plan says that unauthorized, non-plan 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. 
 
Neither the provider in this case nor the referring facility is 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 on 
November 22, 2019 to December 14, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided 
on January 14, 2020 by an OON provider. 
 
You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that you were never 
informed that this provider was no longer in-network with your plan. You also say that you were told there 
would be no charge for the services. The Plan denied your request. The Plan says these services were rendered 
by an OON provider. The Plan also says that this claim was processed correctly according to your 2020 plan 
benefits. 
 
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, you must pay a 30% coinsurance for 
Non-Medicare covered preventive dental services that are received out-of-network. Therefore, we decided that 
the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided on January 14, 
2020 by an OON provider.  
 
Your complaint about the lack of communication with the Plan is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room services (99291, 93010) provided 
February 29, 2020. 
 
You asked the Plan to pay for the Emergency Room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says there was not a correct primary diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99291 & 93010 is not supported in the medical record. Specifically, the primary 
diagnosis code of R65.20, Severe Sepsis is not a valid primary diagnosis. The primary diagnosis must be of the 
underlying infection. Based on this information, we decided that Medicare rules for coverage of the Emergency 
Room services have not been met. Therefore, we decided that the Plan does not have to pay for Emergency 
Room services (99291, 93010) provided February 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 31, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that this provider relied on the facility to get 
proper authorization.  You say that these services were medically necessary and provided in good faith. The 
Plan denied your request. The Plan says unauthorized, non-plan care is not covered. The plan also says that the 
patient's stay at the facility was unauthorized. 
 
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 the medical services provided on March 31, 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 electrical stimulation (G0283) and the office visit (99202) 
provided on March 3, 2020 through March 31, 2020. 
 
You asked the Plan to pay for the electrical stimulation and office visit. You say that you would like 
reconsideration because you were told you would only have a $20 copayment. The Plan denied your request. 
The Plan says coverage extends only to treatment by means of manual manipulation of the spine to correct a 
subluxation. 
 
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 electrical stimulation (G0283) and the office visit (99202) provided on March 
3, 2020 through March 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance provided on June 23, 2020. 
 
You asked the Plan to pay for periodontal maintenance. You say that you want to keep your good health and 
teeth. You say that your dentist told you that you needed 4 cleanings a year due to periodontal disease. The 
Plan denied your request. The Plan says the service is limited to one per calendar year. 
 
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, you also have a maximum benefit of 
one periodontal maintenance every 12 months. The Plan paid for periodontal maintenance provided on 
February 11, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care services you received on 
April 20, 2020. 
 
You asked the Plan to waive the copayment. You say that you should not be responsible for the cost share. The 
Plan denied your request. The Plan says the cost share 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 $65 
copayment for urgently needed services.  
 
Review of the file shows that you were provided urgent care services on April 20, 2020. You have been asked 
to pay a $65 copayment for the services. The services fall within the urgent 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 urgent care services you received on April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on March 19, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you did not get to choose where your biopsy was sent. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says

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 has network providers available who can provide 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 lab work provided on March 19, 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 moderate sedation services (99152) provided on April 30, 
2019. 
 
You asked the Plan to pay for the sedation services. You say that the records provided should support the 
necessity of the service in dispute. The Plan denied your request. The Plan says the medical records do not 
support the service 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 99152 is moderate sedation services. 
 
 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted 
did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level 
of consciousness and physiological status; therefore. Of note, an independent trained observer is someone other 
than the physician performing the services. It is noted that multiple attempts were made to contact the provider 
for additional information. Based on this information, we decided that Medicare rules for coverage of the 
sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate 
sedation services (99152) provided on April 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam you had on February 13, 
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 $35 
copayment for each visit for Medicare-covered exams to diagnose and treat diseases of the eye.  
 
Review of the file shows that you had an eye exam on February 13, 2020. You have been asked to pay a $35 
copayment for the exam. The exam falls within the vision 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 eye exam you had on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis and to waive the coinsurance 
for a Medicare Part B drug provided on March 24, 2020. 
 
You asked the Plan to waive the copayment for arthrocentesis and to waive the coinsurance for a Medicare Part 
B drug. 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 $35 
copayment for specialist services. Your contract with the Plan also clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs.  
 
You received arthrocentesis on March 24, 2020. Therefore, you are responsible to pay the $35 copayment.  
 
You received a Medicare Part B drug on March 24, 2020. The allowed amount is $2,250 and 20% of that is 
$450. 
 
The total amount you owe is: $485. 
 
You have been asked to pay the total amount of $485 for arthrocentesis and a Medicare Part B drug. 
Arthrocentesis falls within the physician/practitioner services, including doctor?s office visits benefit category. 
A Medicare Part B drug falls within the Medicare Part B prescription drugs benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan.  
Therefore, we decided that the Plan does not have to waive the copayment for arthrocentesis and to waive the 
coinsurance for a Medicare Part B drug provided on March 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 
87507 provided on April 7, 2020. 
 
You asked the Plan to pay for the infectious agent detection by nucleic acid services. 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 a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that code 87507 is covered by Medicare in enrollees 
with immunodeficiency. 
 
We looked at the file and Medicare rules. Review of the file does not support immunodeficiency. Based on this 
information, we decided that Medicare rules for coverage of the infectious agent detection by nucleic acid 
services have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent 
detection by nucleic acid services coded 87507 provided on April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 12, 
2020. 
 
You asked the Plan to pay for the subsequent nursing facility care (99309). You say that the treatment was 
medically necessary. The Plan denied your request. The Plan says you did not request prior authorization. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 
87633 provided on December 29, 2019. 
 
You asked the Plan to pay for the infectious agent detection by nucleic acid services. 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 a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that code 87633 is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infectious agent detection by nucleic acid services have not been met. Therefore, we decided 
that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87633 
provided on December 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Zilretta (triamcinolone). 
 
You asked the Plan to pre-approve Zilretta. You say that the enrollee has attempted conservative management 
but has had the most significant relief after use of Zilretta. The Plan denied your request. The Plan says the 
denial of authorization for this drug is correct, because Zilretta is not intended for repeat administration. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 
enrollee does not meet the Medicare criteria for use of Zilretta. Our physician reviewer found Zilretta remains 
experimental for the treatment of the enrollee's condition. More research is needed to show the safety and 
efficacy of Zilretta. 
 
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 not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Zilretta (triamcinolone).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 9, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that this provider relied on the facility to get 
authorization for these services.  You say that these services were medically necessary and provided in good 
faith. The Plan denied your request. The Plan says unauthorized, non-plan 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 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 on March 9, 2020 
by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on January 29, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-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 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 medical services provided to the enrollee by an out-of-network provider 
on January 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services and does 
not have to waive the coinsurance for a prosthetic device provided on January 29, 2020. 
 
You asked the Plan to waive the copayment for outpatient rehabilitation services and to waive the coinsurance 
for a prosthetic device. 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 $35 
copayment for outpatient rehabilitation services. Your contract with the Plan also clearly says that you must 
pay 20% coinsurance for prosthetic devices and related supplies.  
 
You received outpatient rehabilitation services on January 29, 2020. Therefore, you are responsible to pay the 
$35 copayment.  
 
You received an outpatient rehabilitation evaluation on January 29, 2020. Therefore, you are responsible to pay 
the allowed amount of $25.52, which is less than the $35 copayment.  
 
You received a prosthetic device on January 29, 2020. The allowed amount is $189.85 and 20% of that is 
$37.97.  
 
The total amount you owe is: $35 + $25.52 + $37.97 = $98.49.  
 
You have been asked to pay the total amount of $98.49 for outpatient rehabilitation services and a prosthetic 
device. Outpatient rehabilitation services fall within the outpatient rehabilitation services benefit category. A 
prosthetic device falls within the prosthetic devices and related 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 copayment for outpatient rehabilitation services and does not have to waive the 
coinsurance for a prosthetic device provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99212 provided on January 29, 2020. 
 
You asked the Plan to pay for the office 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, we have confirmed that code 99212 
for the office visit has a bundled relationship with code 29550 and cannot be paid as billed. This code cannot be 
paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for the office visit coded 99212 provided on January 
29, 2020.