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

We decided that the Plan does not have to pre-approve Voriconazole. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Voriconazole.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for cardiovascular stress test (93015), Technetium (A9502) and Adenosine injection (J0153) provided on June 16, 2021.
You asked the Plan to waive the cost share for the medical services. You say that you believe these cost shares should be waived. The Plan denied your request. The Plan says the cost shares have processed correctly for these services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for Medicare-covered non radiological diagnostic services, a 20% coinsurance for each Medicare-covered Part B drug and a 20% coinsurance for Medicare-covered medical supplies.
You have been asked to pay a total cost share of $74.66 for the medical services. These services fall within the benefit categories listed in the Medicare rules section. 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 cost share for cardiovascular stress test (93015), Technetium (A9502) and Adenosine injection (J0153) provided on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (CPT code 99203), hospital outpatient clinic visit for assessment and management of a patient (CPT code G0463), arthrocentesis (CPT code 20605) and the office visit (CPT code 99213) provided from March 25, 2021, through July 29, 2021.
You asked the Plan to waive the copayment for the services. You say that you do not think you should be billed for any other charges according to your Plan. The Plan denied your request. The Plan says the claims were processed accordingly with your 2021 EOC 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). Review of the file shows that you received office services (CPT code 99203) and arthrocentesis (CPT code 20605) on March 25, 2021, with the doctor. You were asked to pay a $25 copayment for the visit and arthrocentesis procedure. Review of the file shows that you received outpatient clinic visit services (CPT code G0463) and arthrocentesis (CPT code 20605) on March 25, 2021, at the hospital. You were asked to pay a $234.56 copayment for the facility evaluation and management visit and the arthrocentesis procedure. The Medicare-allowed amount for the outpatient hospital services is less than the set $325 copayment; therefore, you have been asked to pay the lesser amount of $234.56 for the outpatient hospital services. Review of the file shows that you received office services (CPT code 99213) and arthrocentesis (CPT code 20605) on July 29, 2021, with the doctor. You were asked to pay a $25 copayment for the visit and arthrocentesis procedure. Review of the file shows that you received outpatient clinic visit services (CPT code G0463) and arthrocentesis (CPT code 20605) on June 29, 2021, at the hospital. You were asked to pay a $234.56 copayment for the facility evaluation and management visit and the arthrocentesis procedure. The Medicare-allowed amount for the outpatient hospital services is less than the set $325 copayment; therefore, you have been asked to pay the lesser amount of $234.56 for the outpatient hospital services. Your 2021 EOC states that enrollees must pay a $325 copayment for Medicare-covered outpatient hospital and observation services and a $25 copayment for each Medicare-covered specialist visit. 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 office visit (CPT code 99203), hospital outpatient clinic visit for assessment and management of a patient (CPT code G0463), arthrocentesis (CPT code 20605) and the office visit (CPT code 99213) provided from March 25, 2021, through July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99212) provided on June 24, 2021 by an outof-
network (OON) provider.
You asked the Plan to pay for an office visit. You say that this is supported in the records. The Plan denied
your request. The Plan says this was not authorized.
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 an office visit (99212) provided on June 24, 2021
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on January 28, 2021. 
 
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 both Initial Hospital Care and Subsequent Hospital 
Care codes are "per diem" services and may be reported only once per day. 
 
We looked at the file and Medicare rules. The file shows that the Plan paid one unit of initial hospital care for 
this date of service. Further payment is not allowed. 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 initial hospital care rendered on January 28, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital physician services (99223, 99232, 99239) provided from May 7, 2021, to May 9, 2021.
You asked the Plan to waive the coinsurance for inpatient hospital physician services. You say that you received a call from your provider telling you to go to the emergency room because of a blood clot. You also say that you were admitted to the hospital and were informed you did not have a blood clot. The Plan denied your request. The Plan says you were charged the correct coinsurance
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 15% coinsurance for inpatient hospital care, including physician/practitioner services.
You have been asked to pay $56.09 in coinsurance, which is 15% of the allowed amount for inpatient hospital physician services ($373.95 allowed amount x 15% coinsurance = $56.09). 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 inpatient hospital physician services (99223, 99232, 99239) provided from May 7, 2021, to May 9, 2021.
Your complaint about the service you received from the provider and the potential unnecessary inpatient hospital stay 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.
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. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81261, 81264, 88341, 
and G0452) provided to the enrollee on February 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the ordering provider on this claim informed the Plan that they did not have a 
patient matching the details of the Plan's enrollee. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. When the Plan contacted 
the office of the ordering provider on this claim informed the Plan that they did not have a patient matching the 
details of the Plan's enrollee, and that the ordering provider did not order genetic testing for this enrollee. The 
Plan contacted the enrollee who confirmed that they did not have a previous relationship with the ordering 
provider, and we have therefore decided to uphold our original decision at this time; as Genetic Testing not 
ordered by the treating physician is deemed not reasonable or necessary and therefore not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81261, 
81264, 88341, and G0452) provided to the enrollee on February 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (CPT code(s): 80307 and G0483) provided to the enrollee on May 26, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on May 26, 2020, and received by the lab on May 27, 2020. Of note, the patient resides in Texas (TX) and the billing laboratory is located in North Dakota (ND); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Current Procedural Terminology (CPT) code 80307 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on May 26, 2020, and received by the lab on May 27, 2020. Of note, the patient resides in Texas (TX) and the billing laboratory is located in North Dakota (ND); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the drug test (CPT code(s): 80307 and G0483) provided to the enrollee on May 26, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for a coronary artery bypass procedure (33516), endoscopic vein harvest (33508), and operative tissue ablation (33259) provided on April 16, 2021.
You asked the Plan to pay for a coronary artery bypass procedure, endoscopic vein harvest, and operative tissue ablation. You say that these services were billed correctly. The Plan denied your request. The Plan says that these codes are add-on codes without an appropriate primary procedure.
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. The Plan has not provided any reasoning for their denial of code 33516. Although they indicated this code is being handled separately, they did not provided information about the initial denial or the redetermination decision; therefore, the denial cannot be verified. As code 33516 is an appropriate primary code for 33508 and 33259, the denial for these codes is also not substantiated. Therefore, we decided that the Plan has to pay for a coronary artery bypass procedure (33516), endoscopic vein harvest (33508), and operative tissue ablation (33259) provided on April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism (CPT code 87798) provided to the enrollee on November 16, 2020.
You asked the Plan to pay for the screening test. You say that the claim should be paid. The Plan denied your request. The Plan says these services are not authorized because predictive screening testing is not a Medicare benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, the screening test, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism (CPT code 87798) provided to the enrollee on November 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on January 5, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee does not
have symptoms or a diagnosis that would be identified or modified by this testing.
The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed in
the Medicare rules section, are not covered.
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic
testing provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90834) provided on April 27,
2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because
the services were medically necessary. The Plan denied your request. The Plan says there was no
documentation of consultation with the attending or primary care physician in the patient's medical record.
The Plan must follow Medicare rules. Medicare rules say that when services are rendered by a Clinical
Psychologist, if the patient consents, you must attempt to consult their attending or primary care physician
about the provided services and document the consent or declination date to consultations and date of the
consultations in the patient's medical record.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the psychotherapy services have not been met. Specifically, the record does not indicate that a
consultation with the member's primary care physician was rendered. Additionally, there is no referring
physician on the claim. Therefore, we decided that the Plan does not have to pay for the psychotherapy services
(90834) provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the medical services received in Hong Kong from April 7, 2020 to May 
19, 2021. 
 
You asked the Plan to pay for the medical services received in Hong Kong. You say that you would like the 
Plan to reconsider your request. The Plan denied your request. The Plan says that the services received were 
neither emergent nor urgent. 
 
Medicare only covers services provided outside of the United State and its territories under certain specific 
circumstances. These services do not fall under any of the circumstances for which Medicare may cover out-of-
country services. However, the Plan also has a worldwide coverage benefit that goes beyond Medicare 
coverage. For that reason, the Plan's rules apply to this case. The Plan covers worldwide services that would be 
classified as emergency, urgently needed, or post-stabilization care had they been provided in the United 
States. 
 
We looked at the file, the Plan's contract and Medicare rule. The file shows that you saw a provider in Hong 
Kong for evaluation and treatment of glossitis and issues related to polyarteritis nodosa. You submitted receipts 
for payment. You could not have reasonably foreseen requiring these services prior to leaving the Plan's service 
area and the United States. The care provided to you was medically necessary. It would not have been 
medically reasonable to delay the services until you returned to the Plan's service area. Based on this 
information, we decided that Medicare rules for coverage of medical services have been met. Therefore, we 
decided that the Plan has to pay for medical services received in Hong Kong from April 7, 2020 to May 19, 
2021. 
 
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: Practitioner Services
Decision: Partially Favorable

You asked the Plan to waive the cost-sharing for office services. You say that you are being billed $73 and are
requesting reconsideration of these charges. The Plan says that the amounts you are being charged are correct.
We decided that the Plan must waive the cost-sharing for or pay for office services provided from April
15, 2020, to April 29, 2020.
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. You say that you are requesting reconsideration for these charges. The Plan says
that you are being charged $48 for date of service April 15, 2020, $10 for date of service April 21, 2020, and
$10 for date of service April 29, 2020. The Plan did not explain the nature of these charges or whether these
charges reflect cost-sharing for covered services or liability for denied services. Furthermore, the Plan did not
submit a copy of the applicable 2020 Evidence of Coverage. This provider is in-network with the Plan. If these
charges are cost-sharing for covered services, the Plan has not shown that any cost-sharing amounts are
applicable to these dates of service. If these charges are a denial of payment for services, the Plan has not
shown that these services are statutorily excluded from Medicare coverage or that you were given adequate
notice of non-coverage prior to receiving service. Therefore, the Plan has not shown that its decision to hold
you responsible for these charges is correct or justified. Therefore, we decided that the Plan must remove your
liability for office services provided from April 15, 2020, to April 29, 2020.
We also decided that the Plan does not have to waive the cost-sharing for office services provided on
June 28, 2021.
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
copayment for specialist office services. Therefore, we decided that the Plan does not have to waive the costsharing
for office services.
Therefore, we decided that the Plan must reduce your total liability for these claims from $73 to $5.
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 must 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Cinacalcet coded as J0604-AX and unlisted dialysis procedure coded as 90999-G1-V7 provided from February 3, 2021, to June 29, 2021.
You asked the Plan to pay for the medical services. You say that the claims were correctly billed based on the medical documentation provided. The Plan denied your request. The Plan says these claims require corrections before they can be paid.
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 90999 is unlisted dialysis procedure, inpatient or outpatient. The CPT Code Manual definition of code J0604 is cinacalcet, oral, 1 mg, (for end stage renal disease on dialysis).
We find that CPT codes J0604 and 90999 are not supported in the medical record. Specifically, J0604 was billed with a modifier no longer payable by Medicare as of January 1, 2021. As a result, the associated dialysis services associated with this drug administration will also be denied. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for Cinacalcet coded as J0604-AX and unlisted dialysis procedure coded as 90999-G1-V7 provided from February 3, 2021, to June 29, 2021.