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

 
We decided that the Plan does not have to pay for an office visit provided on November 11, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the claim payment denial. 
The Plan denied your request. The Plan says The provider should have verified the member's eligibility, health 
benefits and obtained authorization prior to the member s visit before providing services to the member as 
outlined on the 
member's ID card. 
 
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 provided on November 11, 2021 by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care, per day, for the evaluation and 
management of a patient (99233) provided on July 30, 2021, to August 3, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for subsequent hospital care, per day, for the evaluation and management of a 
patient. You say that the doctor needs to get compensated for her services. The Plan denied your request. The 
Plan says this was denied due to lack of authorization as the member received services out-of-network, and the 
referring provider is not contracted. 
 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 subsequent hospital care, per day, for the 
evaluation and management of a patient (99233) provided on July 30, 2021, to August 3, 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 office visit of a new patient (99204) provided on July 29, 
2021. 
 
You asked the Plan to pay for the office visit of a new patient (99204). You say that the attached 
documentation should be reviewed as the claim denied in error. The Plan denied your request. The Plan says 
this is the incorrect procedure code for established patient per Medicare guidelines. 
 
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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter.  We find that CPT code 99204 is not supported in the medical record. Specifically, the records do not support 
that this was a new patient visit. Based on this information, we decided that Medicare rules for coverage of the 
office visit of a new patient (99204) have not been met. Therefore, we decided that the Plan does not have to 
pay for the office visit of a new patient (99204) provided on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided at the in-network 
benefit level by an out-of-network (OON) provider 
  You asked the Plan to pre-approve a specialist office visit. You say that you would like the out-of-network 
provider to be covered under in-network benefits because of the major cost difference. The Plan denied your 
request. The Plan says the denial of authorization for in-network benefits is correct, because this provider is 
out-of-network with the Plan, and you may choose to visit this provider using your Passport Prime (POP) 
benefits 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees may choose to receive care from out-of-network providers using the Plans Passport 
Prime (POP) benefits. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services at the in-network benefit levels. You may choose to receive 
services from this provider using the Plans Passport Prime (POP) benefits. Therefore, we decided that the Plan 
does not have to pre-approve a specialist office visit to be provided at the in-network benefit level by an out-of-
network (OON) provider
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482). 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0482).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Magnetic Resonance Imaging (MRI) on 
November 27, 2021 
 
You asked the Plan to waive the copayment for a Magnetic Resonance Imaging (MRI). You say that you were 
told the cost of the MRI would cost you $150 and you feel that you should not owe this copay. The Plan denied 
your request. The Plan says per your Evidence of Coverage, you pay $325 per day for other Medicare-covered 
diagnostic radiology services that are not ultrasounds. 
 
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 $325 
copayment for a Magnetic Resonance Imaging (MRI).  
 
You have been asked to pay a $325 copayment for a Magnetic Resonance Imaging (MRI). Magnetic Resonance Imaging (MRI) falls within the Outpatient diagnostic tests and therapeutic services and 
supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a Magnetic Resonance 
Imaging (MRI) on November 27, 2021
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81540) provided on July 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the out-of-network services were not pre-authorized or emergent. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 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 lab services (81540) provided on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on 
November 5, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $55 
copayment for each Medicare-covered urgent care provider visit.  
 
You have been asked to pay a $55 copayment for the Medicare-covered urgent care visit provided. 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 (99214) provided on  
November 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from October 23, 2021, to November 15, 2021. 
 
You asked the Plan to waive the copayments for the PT services. You say that the provider informed you that it 
would only be a $25 copayment per visit. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each therapy visit.  
 
The file shows that you had a total of 8 PT visits. Therefore, you have been asked to pay a $40 copayment for 
each visit for the PT services. The total for all visits is $320 ($40 copayment x 8 visits = $320). The PT 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. 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 copayments for physical therapy (PT) services provided from October 23, 2021, to November 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation services (99226) provided August 27, 2021. 
 
You asked the Plan to pay for the observation services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with a valid place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99226 is not supported in the medical record. Specifically, the claim was billed with an 
outpatient place of service (22), however records show the enrollee was an inpatient at the time services were 
provided. Based on this information, we decided that Medicare rules for coverage of the observation services 
have not been met. Therefore, we decided that the Plan does not have to pay for observation services (99226) 
provided August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that your right foot is swollen causing you issues 
with your balance. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve cardiac care. You say that that you need cardiac care while in Peoria and 
that you wish to establish care with a cardiologist. The Plan denied your request. The Plan says there is 
insufficient evidence to support the medical necessity for the requested services to be performed by a non-Plan 
provider. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
 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 cardiac care. Our reviewer says that you 
do not meet the Medicare criteria for urgent out-of-area care while outside of the plan's service area. Our 
physician reviewer found that the records indicate that the care requested is not medically necessary. It would 
be medically reasonable to delay the services until when the enrollee returned to her service area for up to 6 
Months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cardiac care to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug tests (80307, G0480) rendered by the out-of-
network (OON) provider on November 4, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the drug tests (80307, G0480) rendered by the out-of-network (OON) provider on 
November 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an abdominal ultrasound (76705) provided 
on October 26, 2021. 
 
You asked the Plan to waive the copayment for an abdominal ultrasound. You say that it appears the Plan made 
no payment on your account, leaving you the entire balance of the amount billed by the provider. You also say 
you have not been informed of any reason the Plan would not make payment, and the provider is still expecting 
payment. You also say that you will make your payment of the copayment as soon as payment is made to the 
provider by the Plan. The Plan denied your request. The Plan says you were charged the correct cost sharing 
amount.  
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 
copayment for Medicare covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or at a free-standing facility such as a radiology center or medical clinic).You contract with 
the Plan also clearly says that the diagnostic radiology services require specialized equipment beyond standard 
x-ray equipment and must be performed by specially trained or certified personnel, and this includes, but is not 
limited to ultrasounds.  
 
You have been asked to pay $135.70, which is less than the $160 copayment for an abdominal ultrasound. An 
abdominal ultrasound falls within the outpatient diagnostic tests and therapeutic 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 abdominal ultrasound (76705) provided on October 26, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and intraoral x-
rays (D0210) provided by a network provider on November 12, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation (D0150) and the intraoral x-rays (D0210). 
You say that you were not informed that new patient exams and x-rays were not covered. The Plan denied your 
request. The Plan says the services exceeded the maximum allowed per period. 
 
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. The record shows you received a comprehensive oral exam and 
intraoral x-rays on October 11, 2019, which exhausted the benefits. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation (D0150) and intraoral x-rays (D0210) provided by a 
network provider on November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic 
x-ray (D0330) provided on November 23, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you 
thought these services would be covered by the Plan. The Plan denied your request. The Plan says these 
services exceed the maximums allowed per period. 
 
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, comprehensive oral evaluation 
(D0150) and panoramic x-ray (D0330) are each limited to one procedure every three plan years. The record 
shows that you received a comprehensive oral evaluation (D0150) on June 10, 2020, and a panoramic x-ray 
(D0330) on June 4, 2020 and your comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) 
benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) and panoramic x-ray (D0330) provided on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for 6 PAP filters dispensed at one time.

You asked the Plan to provide coverage for 6 filters at a time to cover 3 months of use. The Plan denied your
request. The Plan says Medicare does not allow this dispensing request. Maximus overturned the Plans denial
stating this request was within the allowed limits. The Plan requested a reopen and states that Medicare only
allows 2 filters to dispensed in a 1-month period. More than two filters will not be allowed with in 30 days.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare will only cover 2 filters in a
30-day period. Any quantities dispensed over 2 per month will not be covered within the 30 days. Therefore,
we decided that the Plan does not have to provide coverage for 6 PAP filters every three months to be
dispensed at one time.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the flexible protective outer surface covering system (L5962).

You asked the Plan to pre-approve the flexible protective outer surface covering system. You say that the extra protection is not medically necessary. The Plan denied your request. The Plan says there is no medical need for the extra protection offered by the outer surface covering system.

The Plan follows Medicare rules. Medicare rules say that protective outer covering systems are used by a beneficiary who has special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, L5706, and L5707. They are not for cosmetic or convenience reasons, or for everyday usage in a typical environment.

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 the flexible protective outer surface covering system. Our reviewer says that the requested item is not medically necessary for the enrollee's condition. Our physician reviewer found protective outer surface covering systems (L5962) is not medically necessary per Local Coverage Article: Lower Limb Prostheses - Policy Article (A52496). The documentation does not reveal that the patient has special needs for protection against unusually harsh environmental situations beyond the level of protection that is afforded by L5704.

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 flexible protective outer surface covering system have not been met. Therefore, we decided that the Plan does not have to pre-approve the flexible protective outer surface covering system (L5962).