Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for scanning computerized ophthalmic 
diagnostic imaging (92134) intravitreal injection of a pharmacologic agent (67028) injection, aflibercept, 1 mg 
(J0187) provided August 25, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic and injection services. You say that your 
secondary insurance has not picked up the costs and they were billed to you. The Plan denied your request. The 
Plan says this claim was processed correctly per the plan benefits. 
 
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 $50 
copayment specialist visits 20% coinsurance for Part B drugs administered by a provider for 
Physician/Practitioner services, including doctor's office visits and Medicare Part B prescription drugs.  
 
You have been asked to pay $211.69 $50 copayment for the diagnostic and injection services. The plan had 
paid and the initial balance left was $430.42. The secondary insurance then paid $218.73 leaving $211.69. The 
diagnostic and injection services falls within the Physician/Practitioner services, including doctor's office visits 
and 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 scanning computerized ophthalmic diagnostic imaging (92134) intravitreal injection of a pharmacologic 
agent (67028) injection, aflibercept, 1 mg (J0187) provided August 25, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endoscopy rendered on May 23, 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 procedure code 43239 is not supported. 
 
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 43239 is esophagogastroduodenoscopy, flexible, 
transoral; with biopsy, single or multiple. 
 
We find that CPT code 43239 is not supported in the medical record. Specifically, there is no documentation 
that an esophagogastroduodenoscopy was performed. 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 the endoscopy rendered on May 23, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician service provided to the enrollee on May 1, 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 this service required a corrected claim which was not submitted until after the filing 
limit. 
 
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 valid claim for 
this service was not filed until August 28, 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 
physician service provided to the enrollee on May 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the CT scan of the left leg provided on 
June 29, 2020. 
 
You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. 
You say that you have submitted a corrected claim with the diagnosis codes updated, including on for pain in 
the left hip joint. The Plan denied your request. The Plan says the original claim was correctly denied since it 
was reported with an unspecified side diagnosis code when the x-ray was provided to the left leg. 
 
The Plan must follow Medicare rules. Medicare rules say that providers should report the unspecified side 
diagnosis code only when the laterality is not documented in the record. 
  
In this case, the file shows that the provider was aware that the diagnosis was referring to the left side, but an 
unspecified side diagnosis was reported. This is not correctly billed based on the above rules. Therefore, we 
decided that the Plan does not have to pay for the interpretation of the CT scan of the left leg provided on June 
29, 2020.  
 
We note that it appears a corrected claim was submitted directly to Maximus during the review of this case. We 
cannot act on or process claim corrections. Corrected claim information may be submitted directly to the Plan 
for further review. We are only permitted to make a decision based on the claim information reviewed by the 
Plan for payment. Please submit any corrections or additional claim information directly to the Plan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray provided on August 4, 2020. 
 
You asked the Plan to pay for the panoramic x-ray. You say that the dentist didn't tell you the x-ray wasn't 
covered so you thought it was. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 
panoramic x-ray provided on August 4, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility (99308) care provided on 
August 10, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that medically necessary services were rendered in 
good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network 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 for the subsequent nursing facility (99308) care 
provided on August 10, 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 lab work provided on April 23, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. 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 lab work provided on April 23, 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 physician services provided August 14, 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 a valid claim for this service was not received until after the required time frame to file. 
 
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 valid claim for 
this service was not filed until September 8, 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 
physician services provided August 14, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the hospital services provided on July 10, 2020, through July 13, 2020. 
 
You asked the Plan to pay for the hospital services. You say that you would like reconsideration because the 
member was discharged with home care. The Plan denied your request. The Plan says that the "From" and 
"Through" dates on the claim are not consistent with a same day transfer. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code  is supported in the medical record. Specifically, this claim has been billed with 
condition code 40 which indicates a same day transfer. The record indicates that the member was admitted and 
discharged on July 13, 2020, validating the same day transfer condition code. Based on this information, we 
decided that Medicare rules for coverage of the hospital services have been met. Therefore, we decided that the 
Plan has to pay for the hospital services provided on July 10, 2020, through July 13, 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 physician services provided on August 25, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician 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. The Plan says that there was 
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 for physician services provided on August 25, 2020 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has been hospitalized for a period of 
time and needs to recover at a rehab facility. The enrollee does require physical therapy and occupational 
therapy services but does not require an intensive inpatient rehabilitation therapy program. Care at the skilled 
nursing facility level appears to be appropriate in this case. The Plan denied your request. The Plan says the 
guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the services 
needed in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arthrocentesis procedure provided on 
August 28, 2020. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you have received this service 
before but did not have to pay this fee. The Plan denied your request. The Plan says the copayment amount you 
are being charged is correct. 
 
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 $225 
copayment for in-network outpatient surgery at an outpatient hospital.  
 
You have been asked to pay $225 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 arthrocentesis procedure 
provided on August 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from September 19, 2019, 
through September 25, 2019. 
 
You asked the Plan to pay for inpatient hospital care. You say that the service was medically necessary. The 
Plan denied your request. The Plan says complete medical records for the case was not received and, therefore, 
cannot be reviewed. 
 
The Plan follows Medicare rules. Medicare rules say that when a care provider takes an action that results in 
unnecessary admissions, premature discharges and readmissions, multiple readmissions or other inappropriate 
medical or other practices with respect to beneficiaries or billing for services, CMS authorizes QIOs to take 
certain actions, including denial of payment. 
 
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 inpatient hospital care. Our reviewer says 
that the service does not meet criteria for readmission. Our physician reviewer found that while the admission 
was medically necessary, it is clear that it was due to inadequate treatment from the initial hospitalization as the 
patient was readmitted with an exacerbation of the prior problem. 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital care have not been met. Specifically, the patient returned to 
the hospital due to inadequate treatment during the initial hospitalization. This means readmission does not 
apply for this case. Therefore, we decided that the Plan does not have to pay for inpatient hospital care 
provided from September 19, 2019, through September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 3, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they 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 did not pre-approve the 
physician?s services. 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 physician's services provided on September 3, 2020.
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 August 31, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this 
copayment. 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 $295 
copayment for outpatient surgery/in-network/surgery services.  
 
You have been asked to pay a $295 copayment for an outpatient surgery. The injection that was provided is 
considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls 
within the outpatient surgery/in-network/surgery services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an outpatient surgery provided by a participating provider on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating
provider on August 10, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that the wrong injection was approved.
The Plan denied your request. The Plan says the correct coinsurance 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 20%
coinsurance for Medicare Part B prescription drugs/in-network.
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed
amount is $1,863.54. The total amount you are being asked to pay is $372.71 ($1,863.54 x 20 % = $372.71).
The correct coinsurance has been applied to the injection that was received. An injection falls within the
Medicare Part B prescription drugs/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
coinsurance for an injection provided by a participating provider on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interim partial lower denture (D5821) provided on July 
30, 2020. 
 
You asked the Plan to pay for the dental item. You say that the plan materials state that extractions and lower 
partial dentures are covered. You say that you rely on your provider regarding services necessary for the 
salvation of a small amount of working teeth. You also say that you thought you could rely on insurance to 
offset a portion of the cost. The Plan denied your request. The Plan says the interim partial lower denture is not 
listed as a covered service. The Plan also says that any services not listed are 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. Therefore, we decided that the Plan does not have to pay for the 
interim partial lower denture (D5821) provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on April 23, 2019.You asked the Plan to waive the copayment for a specialist office visit. You say that you should only have a $5 copayment. You say that you had to go in for an emergency and your PCP was not available. 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 $50 copayment for physician/practitioner services/in-network/specialist visit. You have been asked to pay a $50 copayment for a specialist office visit. A nurse practitioner is considered a specialist; therefore, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/in-network/specialist visit 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 office visit provided by a participating provider on April 23, 2019.