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

 
We decided that the Plan does not have to pay for moderate sedation services provided on February 20, 2020. 
 
You asked the Plan to pay for the moderate sedation services. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says there is no documentation supporting that the service was medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
In this case, the CPT Code Manual definition of code Moderate sedation services provided by the same 
physician or other qualified health care professional performing the diagnostic or therapeutic service that the 
sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the 
patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 
years or older  
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there are no medical records 
clearly documenting necessity of the moderate sedation. Based on this information, we decided that Medicare 
rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan 
does not have to pay for moderate sedation services provided on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more forthe comprehensive oral evaluation, intraoral complete series x-ray and prophylaxis provided on April 20, 2020.You asked the Plan to pay more forthe comprehensive oral evaluation, intraoral complete series x-ray and prophylaxis. You say that you are disputing a balance of $394.The Plan denied your request. The Plan says the claim processed correctly.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 Plan is only obligated to pay the allowed amount for a comprehensive oral evaluation, intraoral complete series x-ray and prophylaxis when received from an out-of-network provider. You are responsible for the difference between the billed and allowed amount.Therefore, we decided that the Plan does not have to pay more forthe comprehensive oral evaluation, intraoral complete series x-ray and prophylaxis provided on April 20, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgenetic screening testing provided on April 27, 2020.You asked the Plan to pay forgenetic testing. You say that you were under the impression that authorization for this testing was approved.The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation does not support that you are at risk or that this panel testing would improve clinical outcomes.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 tests at issue in this appeal, genetic testing, were requested for screening purposes. Medicare does not cover these tests for screening purposes.Therefore, we decided that the Plan does not have to pay forgenetic screening testing provided on April 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on May 5, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed services cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe lab services provided on May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the specialist office visit and x-rays you 
had, the specialist office visit, x-ray and injection you had, and the 
specialist office visit and needle electromyography. 
 
You asked the Plan to waive the cost sharing for the specialist office visits, x-rays, injections, and needle 
electromyography. You say that you should only have to pay one copayment for each of these visits. 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 a $45 
copayment for specialist office visits, a $30 copayment for x-rays, a $30 copayment for non-radiological 
diagnostic tests, and 20% coinsurance for Part B drugs. 
 
Records show that, you had a specialist office visit and x-rays.  You were charged a $45 
copayment for the office visit and a $30 copayment for the x-rays.  This means that you have been asked to pay 
the correct amount based on your contract with the Plan for this date of service. Records 
show that you had a specialist office visit, and x-ray, and a Part B drug injection.  You were charged a $45 
copayment for the office visit, a $40 copayment for the x-ray, and 20% coinsurance for the injection. This 
means that you have been asked to pay the correct amount based on your contract with the Plan for this date of 
service.  Finally, you had a specialist office visit and a needle electromyography (which is a 
type of non-radiological diagnostic test.)  You were charged a $45 copayment for the office visit and a $30 
copayment for the needle electromyography. This means that you have been asked to pay the correct amount 
based on your contract with the Plan for this date of service.   
 
These cost sharing amounts are contractual obligations you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the cost sharing for the specialist office visit and x-
rays you had, the specialist office visit, x-ray and injection you had, 
and the specialist office visit and needle electromyography you had.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
therapy rendered on March 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that TENS for CLBP is covered when part of a Medicare-
approved clinical study that meets specific criteria. 
 
We looked at the file and Medicare rules. The file shows that the services were rendered for CLBP but were not 
associated with a Medicare-approved clinical study. 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 transcutaneous electrical nerve stimulation (TENS) therapy rendered on March 23, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tangential biopsy of the skin (11103) provided on March 3, 
2020. 
 
You asked the Plan to pay for the biopsy. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says CPT code 11103 was not billed with an appropriate 
primary 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. In this case, we have confirmed that code the 
biopsy has not been billed with an appropriate primary procedure code 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 a tangential biopsy of the skin (11103) 
provided on March 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment. 
 
You asked the Plan to pay for waive the copayment. You say that the provider is charging you for the x-ray. 
The Plan denied your request. The Plan says you cannot be balance billed but you do have a copayment. 
 
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 $10 
copayment, for Physician/Practitioner services.  
 
You have been asked to pay a $10 copayment, for Radiologic examination, knee (cpt 73560). Radiologic 
examination, knee (cpt 73560) falls within the Physician/Practitioner 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by an in-
network provider on April 24, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you just had a staff member 
send a readout. You say that this was not an office visit. 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 $20 
copayment for physician/practitioner services/in-network.  
 
You have been asked to pay a $20 copayment for specialist services. The correct copayment has been applied 
to the services provided. Specialist services fall within the physician/practitioner services/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 specialist services provided by a participating 
provider on April 24, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the skilled nursing facility (SNF) and 
physical and occupational therapy services rendered from February 27, 2020 to April 24, 2020. 
 
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the cost sharing 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 5% of 
the total cost per admission for days 1-100 for SNF care and a $25 copayment per therapy, per provider, per 
visit for outpatient rehabilitation services. 
 
Review of the file shows that you received SNF services from February 27, 2020 to February 29, 2020 and 
from March 1, 2020 to March 31, 2020. You have been asked to pay 5% of the total cost for these services, for 
a total of $970.44. These services fall within the SNF care benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan.  
 
The file shows that you received physical and occupational therapy services for 10 dates of service from April 
11, 2020 to April 24, 2020. You have been asked to pay a $25 copayment per day for these services for 9 dates 
of service. You have been asked to pay a copayment of $12.97 for the services on April 16, 2020, as you had 
met your maximum out of pocket amount when this claim was processed. The total amount you have been 
asked to pay for these services is $237.96. These services fall within the outpatient rehabilitation services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. 
The total amount you have been asked to pay for these services is $1,208.41. 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 cost sharing for the skilled nursing facility (SNF) and physical and occupational therapy services 
rendered from February 27, 2020 to April 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee replacement. 
 
You asked the Plan to pre-approve a total knee replacement. You say that total knee replacement is medically 
necessary. The Plan denied your request. The Plan says records did not show any x-rays of the knee to show 
the amount of deterioration of the joint. 
 
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 a total knee replacement. Our reviewer 
says that a total knee replacement is not medically necessary at this time. Our physician reviewer found there is 
no specific radiographic evidence documented by the physician in the submitted medical records, and no 
radiology reports have been submitted. There is no documentation of unsuccessful appropriate conservative 
therapy clearly documented in the pre-procedure submitted medical records. At this time, the enrollee did not 
have a diagnosis, condition, and/or symptoms that meets the criteria for coverage of total knee replacement. 
Therefore, this request for right total knee replacement would not be considered medically reasonable and 
necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a total knee replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee replacement.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the office visit and eye refraction provided on August 14, 2019. 
 
You asked the Plan to pay for the office visit and eye refraction. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the services rendered are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the correct Evidence of Coverage (EOC) for the 
billed date of service year 2019 was not provided. Maximus requested the EOC on two separate occasions with 
no response. No documentation was provided to show that services from a non-contracted provider require 
prior authorization. The plan has not substantiated their denial. Therefore, we decided that the Plan has to pay 
for the office visit and eye refraction provided on August 14, 2019.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a portable oxygen concentrator provided to the enrollee on December 
26, 2019. 
 
You asked the Plan to pay for the concentrator. You say that this was necessary to continue duties as a fire 
police captain. The Plan denied your request. The Plan says that there is lack of information. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Additionally, Medicare rules say that a contract provider is an agent of the plan. Services and 
referrals given by a contract provider are considered approved by the plan unless notice is provided that the 
services will not be covered. The Plan follows these rules. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial. The plan has stated that they were 
unable to obtain a proof of payment/itemized bill for the item. However, an itemized sales receipt for the 
concentrator was provided in the case file. This is sufficient to verify this service. Additionally, it appears that 
the concentrator was prescribed by the PCP. The PCP is a contract provider, so this should mean that the 
concentrator is considered approved. The file does not show that the plan provided notice that the concentrator 
would not be covered. Therefore, we decided that the Plan has to pay for a portable oxygen concentrator 
provided to the enrollee on December 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for vision services received on May 29, 2020. 
 
You asked the Plan to reimburse you for the services. You say that you would like to be reimbursed. The Plan 
denied your request. The Plan says the claim was processed appropriately. 
 
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.  
 
We looked at the file and the Plan's rules. The $59 that you are requesting cannot be reimbursed. Medicare does 
cover this type of exam. Based on this information, we decided that the Plan's rules for coverage of the services 
have not been met. Therefore, we decided that the Plan does not have to reimburse you for vision services 
received on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99232-24). 
 
You asked the Plan to pay for hospital care. You say that this was unrelated to the enrollee's surgery. The Plan 
denied your request. The Plan says the records do not support this was unrelated. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will pay for an evaluation and 
management service other than inpatient hospital care before discharge from the hospital following surgery 
(CPT codes 99221-99238) if it was provided during the postoperative period of a surgical procedure, furnished 
by the same physician who performed the procedure, billed with CPT modifier ?-24,? and accompanied by 
documentation that supports that the service is not related to the postoperative care of the procedure. It does not 
pay for inpatient hospital care that is furnished during the hospital stay in which the surgery occurred unless the 
doctor is also treating another medical condition that is unrelated to the surgery. 
 
We looked at the file and Medicare rules. The record shows that the services at issue were performed during 
the hospital stay in which a pacemaker insertion (33208) was performed. The records do not show that the 
services at issue were unrelated to the surgery and modifier 24 is not supported. Based on this information, we 
decided that Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for hospital care (99232-24).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for upper eyelid blepharoplasty (15823). 
 
You asked the Plan to pay for upper eyelid blepharoplasty. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was cosmetic. 
 
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 pay for upper eyelid blepharoplasty. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the are no clinical records in the case file for review. There are no photographs, and 
there are no results of visual field testing. The documentation does not support that the upper eyelid 
blepharoplasty was medically reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upper eyelid blepharoplasty have not been met. Therefore, we decided that the 
Plan does not have to pay for upper eyelid blepharoplasty (15823).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service and ground mileage. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the ambulance ride was 
a necessary service. You also say that you asked if the medical transport was covered by insurance, and were 
told yes. The Plan denied your request. The Plan says the enrollee was enrolled in a hospice program at the 
time the transport service was provided. The Plan also says that when an enrollee enrolls in a Medicare-
certified hospice program, the enrollee's hospice services, and any Medicare Part A and Part B services related 
to their prognosis are covered by Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service and ground mileage.