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

 
We decided that the Plan does not have to waive the deductible for physician services provided by a 
participating provider on March 4, 2020. 
 
You asked the Plan to waive the deductible for physician services. You say that you thought that this would be 
covered. The Plan denied your request. The Plan says the deductible amount had not been met at the time of 
these services; therefore, the correct deductible has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible for physician services/out-of-network.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category physician 
services/out-of-network. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
a $750 deductible for physician services/out-of-network. This cost sharing is a contractual obligation that had 
not been met at the time physician services was received on March 4, 2020. The total amount you are being 
asked to pay is $749.99. Therefore, we decided that the Plan does not have to waive the deductible for 
physician services provided by a participating provider on March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 8, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 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 the medical services provided on May 8, 2020 by 
an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjacent tissue transfer or rearrangement, any area, each 
additional 30.0 sq. cm. (14302) provided May 20, 2019. 
 
You asked the Plan to pay for adjacent tissue transfer or rearrangement. You say that please review the 
additional medical documentation for the CPT code 14302 that was denied on the original medical 
documentation that the medical notes do not support. The Plan denied your request. The Plan says the 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 requested CPT code was not 
documented in the narrative of the operative report, as a separate procedure.  
 
 
 
 
The requested CPT is an add-on code and the primary procedure code is not listed. 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 adjacent tissue transfer or rearrangement, any area, each 
additional 30.0 sq. cm. (14302) provided May 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on March 9, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 diagnostic radiology services provided on March 9, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided 
from February 1, 2020 to February 17, 2020. 
 
You asked the Plan to pay for the SNF care. You say that the inpatient skilled nursing facility care was 
medically necessary for the enrollee. The Plan denied your request. The Plan says the inpatient skilled nursing 
facility care was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 pay for the SNF care. Our reviewer says that the 
inpatient skilled nursing facility care was not medically necessary. Our physician reviewer found that as of 
February 1, 2020, the enrollee did not require any skilled nursing or rehabilitation services on a daily basis. She 
was not expected to make measurable gains within a reasonable and predictable period of time. She did not 
require skilled therapy to prevent deterioration with mobility or activities of daily living. The enrollee did not 
require skilled therapy to establish a safe and effective maintenance program. Additionally, as a practical 
matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care. 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the inpatient skilled nursing facility (SNF) care provided from February 1, 2020 to February 17, 
2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation. 
 
You asked the Plan to pay for psychiatric diagnostic evaluation. You say that it is the facility's responsibility to 
obtain prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by 
the provider or the facility; therefore, payment has been properly denied. 
 
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 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 psychiatric diagnostic evaluation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee from May 29, 
2018 to May 30, 2018. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria were not 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. 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 these services. Our reviewer says that Medicare billing criteria are not met. Our physician 
reviewer found documentation included billing statement for 2 units of CPT 93970 for dates of service May 28, 
2018 and May 29, 2018, however, no documentation of the reports was found in the documentation submitted.  
Therefore, correct coding cannot be verified. We looked at this physician's review, the file, and Medicare rules. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee from 
May 29, 2018 to May 30, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202)  provided February 10, 
2020. 
 
You asked the Plan to pay for the outpatient office visit. You say that you hurt your back working in your yard 
using your lawn mower and leaf bagger. The Plan denied your request. The Plan says this service is not 
covered under the plan benefits under any normal circumstances. 
 
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 outpatient office visit (99202)  provided February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the hospital services, durable medical 
equipment, and injectable drugs you received from January 7, 2020 through March 30, 2020. 
 
You asked the Plan to waive the cost sharing for the hospital services, durable medical equipment, and 
injectable drugs. You say that you should not have to pay this cost sharing because the surgery you had caused 
all of these problems. The Plan denied your request. The Plan says you were charged this cost sharing 
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 the 
following cost sharing amounts: a $340 copayment for outpatient hospital observation services,  a copayment 
of $340 per day for days 1-5 for inpatient hospital care, 20% coinsurance for durable medical equipment, and .  
20% coinsurance for Medicare Part B-covered drugs.   
 
Records show that you were in hospital observation from January 7, 2020 through January 9, 2020.  The Plan 
has charged you $340 for these hospital observation services. Your contract says that you pay $340 for hospital 
observationservices, so this cost sharing was assessed correctly.  In addition, you received a boot, a type of 
durable medical equipment, on January 30, 2020.  The plan charged you 20% coinsurance for this item. Your 
contract clearly states that you pay 20% coinsurance for durable medical equipment, so this amount was 
charged correctly.  You were also admitted to the hospital as an inpatient from February 16, 2020 through 
February 21, 2020, a total of 5 days.  You contract says that you pay a $340 copayment per day for days 1-5 for 
inpatient hospital care, so this cost sharing was assessed correctly.  Finally, you were charged 20% coinsurance 
for the injectable drugs you received from your doctor from February 23, 2020 through March 30, 2020. Your 
contract says that you pay 20% coinsurance for Medicare Part B-covered drugs such as injectable drugs you 
receive from a doctor.  This means that you have been correctly charged this coinsurance. 
 
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. Your dissatisfaction with your care 
does not negate this contractual obligation. Therefore, we decided that the Plan does not have to waive the cost 
sharing for the hospital services, durable medical equipment, and injectable drugs you received from January 7, 
2020 through March 30, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on June 21, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that it is the facility's responsibility to obtain 
prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 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 skilled nursing services provided on June 21, 2019 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the services provided from January 6, 2020 
through May 25, 2020 by an in-network provider. 
 
You asked the Plan to waive the copayment for the services. You say that you have not had to pay a $30 
copayment ever for the provider's office to read your machine remotely and now since 2020 you are being 
charged $30 each time and you aren't even going into the office for this. The Plan denied your request. The 
Plan says per review of call history, there is no indication you contacted the plan  prior to verify  benefits and 
no misinformation was provided the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you received services from January 6, 2020 through May 25, 2020 provided by 
an in-network provider. Your EOC states, "enrollees must pay a $30 copay for visits to in-network specialists. 
Covered services include: Medically-necessary medical care or surgery services furnished in a physician?s 
office, certified ambulatory surgical center, hospital outpatient department, or any other location. Consultation, 
diagnosis, and treatment by a specialist. Certain telehealth services including consultation, diagnosis, and 
treatment by a physician or practitioner for patients in certain rural areas or other locations approved by 
Medicare. Brief virtual (for example, via telephone or video chat) 5-10 minute check-ins with your doctor?if 
you are an established patient and the virtual check-in is not related to an office visit within the previous 7 
days, nor leads to an office visit within the next 24 hours or soonest available appointment. Remote evaluation 
of pre-recorded video and/or images you send to your doctor, including your doctor?s interpretation and follow-
up within 24 hours?if you are an established patient and the remote evaluation is not related to an office visit 
within the previous 7 days, nor leads to an office visit within the next 24 hours or soonest available 
appointment. Consultation your doctor has with other physicians via telephone, internet, or electronic health 
record assessment?if you are an established patient." 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 services provided from January 6, 2020 through May 25, 2020 by an in-network provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for Hyaluronan or genvisc 850 (J7320) provided on March 9, 2020. 
 
You asked the Plan to pay for the injection. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that the documentation submitted does not support the 
dosage 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 J7320 is Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg. 
 
We asked our coder 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 injection. Our reviewers say that CPT code J7320 meets 
criteria for billing and reimbursement consideration. Our reviewer found each prefilled syringe of GenVisc 
contains 10mg/mL of sodium hyaluronate per 2.5mL. This is billed at 25 units.  Authorization is in place to 
cover drug. The medical records indicate "a 2.5cc pre-filled genvisc 850 syringe" was injected into the joint 
space." Therefore, J7320 (25 units) is eligible for reimbursement. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have been met. Therefore, we decided that the Plan has to pay for 
Hyaluronan or genvisc 850 (J7320) provided on March 9, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 18, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that in the case of a clinical laboratory test provided under 
an arrangement made by a hospital, CAH or SNF, payment is made to the hospital or SNF. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were provided under 
arrangement by a hospital. Payment for these services is included in the facility payment. Therefore, we 
decided that the Plan does not have to pay for the laboratory services rendered on February 18, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from November 25, 
2019 to December 24, 2019. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
required no nursing services which would be considered skilled services by Medicare. The Plan also says that 
the enrollee had no skilled therapy or skilled nursing service needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from November 25, 2019 to December 24, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on May 13, 2020. 
 
You asked the Plan to waive the copayment for an injection. You say that you had three injections in less than a 
half hour. You say that this should not count as surgery. 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 $400 
copayment for outpatient surgery/in-network.  
 
You have been asked to pay a $400 copayment for an injection. The injections you received are considered an 
outpatient surgery; therefore, the correct copayment has been applied. An injection 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 outpatient surgery 
provided by a participating provider on May 13, 2020.