Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on April 22, 2020 to April 23, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you left at 3:00am 
because you were not getting any help. You say that you do not feel like you should have to pay for the 
overnight stay. 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 $415 
copayment per day for days 1-4. There is a $0 copayment for days 5-90 for inpatient hospital care/in-network.  
 
You have been asked to pay a $415 copayment per day for an inpatient hospital stay. The total amount you are 
being asked to pay is $415. The correct copayment has been applied to the services that were provided. An 
inpatient hospital stay falls within the inpatient hospital care/in-network benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on 
April 22, 2020 to April 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 3, 2019 by an out-of-
network provider. 
 
You asked the Plan to pay for the medical services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is no valid referral for this service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on May 3, 2019 by 
an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a PSA measurement (84153) performed on 
April 28, 2020. 
 
You asked the Plan to waive the copayment for a PSA measurement. You say that you should not be charged 
for this service. The Plan denied your request. The Plan says the correct copayment was 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 $10 
copayment for Medicare-covered lab services per day per provider.  
 
You have been asked to pay a $10 copayment for a PSA measurement. A PSA measurement 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 PSA measurement (84153) performed on April 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Hepatobiliary system imaging services provided on June 25, 
2018. 
 
You asked the Plan to pay for the imaging services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the claim was untimely. 
 
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 claim for the imaging services was not filed until December 27, 2019. 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 Hepatobiliary system imaging services provided on June 25, 
2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided to the enrollee on 
March 9, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the appealing provider believes the claim should be 
paid. The Plan denied your request. The Plan says the services are not supported by the records. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the orthosis. Our reviewer says that the 
enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the documentation in the 
case file does not support that the requested wrist/hand orthosis was medically reasonable and necessary for the 
enrollee in this case. An appropriate history and a physical examination of the wrist would reasonably be 
required to adequately assess whether the wrist/hand orthosis was medically reasonable and necessary. The 
documentation does not support that the wrist/hand orthosis was medically reasonable and necessary in this 
case, as there is insufficient documentation of a credible physical examination of the wrist. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for wrist hand orthosis (L3916) provided to the enrollee on March 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by on April 12, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 12, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on February 18, 
2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like reconsideration because 
this supply is medically necessary. The Plan denied your request. The Plan says the records and member's 
claim do not support that a face-to-face exam occurred between the ordering physician and the member. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis 
(L0650) provided on February 18, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the duplex scan provided to the enrollee on March 13, 2020. 
 
You asked the Plan to pay for the duplex scan. The Plan denied your request. The Plan says that this is not 
covered for the diagnosis in question. 
 
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. 
 
You were provided the duplex scan by a contract provider. The file does not show that the Plan provided notice 
that the duplex scan would not be covered. Under Medicare rules, this means the duplex scan is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the duplex scan provided to the 
enrollee on March 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to reduce the total copayment amount for an inpatient hospital stay from 
December 16, 2019 to December 20, 2019. 
 
You asked the Plan to reduce the total copayment amount for an inpatient hospital stay. You say that you were 
only in the hospital for 3 nights and disagree with being charged an additional day. The Plan denied your 
request. The Plan says that the claims were processed correctly, and you are being charged the correct amount. 
 
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 did not provide medical records. Without medical records we cannot 
determine whether or not you were in the hospital for 4 days. We decided the Plan can only charge you an 
inpatient hospital copayment for 3 days. Therefore, we decided that the Plan has to reduce the total copayment 
amount for an inpatient hospital stay from December 16, 2019 to December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on October 22, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that this doctor is a specialist in this field and 
you feel like this is the doctor you need to see. 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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a specialist office visit provided on October 22, 
2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from February 13, 2020 
to March 13, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the clinical 
information received did not establish medical necessity for the requested services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from February 13, 2020 to March 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the oral evaluation, extraction and endosteal implant 
provided on May 11, 2020. 
 
You asked the Plan to pay more for the oral evaluation, extraction and endosteal implant. You say that there are 
no approved dentists in your area. You say that you should be fully reimbursed. 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 Plans 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 50% 
of the allowed amount for your covered dental services from an out-of-network provider.  
 
Services Billed Amount Allowed Amount Coinsurance Member Liability 
Oral Evaluation $75 $75 50% $37.50 
Extraction $285 $285 50% $142.50 
Endosteal Implant $2100 $0 Not Covered $2100 
TOTAL:    $2,280 
 
  
Therefore, we decided that the Plan does not have to pay more for the oral evaluation, extraction and endosteal 
implant provided on May 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on May 8, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you were told that you would only owe a 
$30 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are 
being charged the correct 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 $200 
copayment for an MRI.  
 
You have been asked to pay a $200 copayment for an MRI. An 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 
an MRI provided on May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 29, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says on-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
laboratory 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 laboratory services provided on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 27, 2020 by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that you verified over the phone that the claims 
denied because an authorization was required and the Plan would not allow a retro auth. The Plan denied your 
request. The Plan says these visits to a non-contracted pain management clinic were not authorized and all 
services provided outside of the network must be pre-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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on April 27, 2020 
by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a transesophageal echocardiography 
procedure (93312) and a cardioversion procedure (92960) performed on January 10, 2020. 
 
You asked the Plan to waive the copayments for a transesophageal echocardiography procedure and a 
cardioversion procedure. You say that you were quoted a lower price prior to the procedures and that you 
refuse to pay for substandard care. The Plan denied your request. The Plan says the correct copayments were 
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 $250 
copayment for each covered diagnostic procedure or test at a network outpatient facility. Your contract with the 
Plan also clearly says that you must pay a $285 copayment for each covered surgical or observation room 
service you get at an outpatient hospital. 
 
You have been asked to pay a $250 copayment for a transesophageal echocardiography procedure and a $285 
copayment for a cardioversion procedure. A transesophageal echocardiography procedure falls within the 
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. A cardioversion procedure 
falls within the "Outpatient hospital 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 a transesophageal echocardiography procedure (93312) and a cardioversion procedure (92960) performed 
on January 10, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review. 
 
Your complaint about receiving erroneous or misleading information about the copayment from the provider 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for removal of torus mandibularis (D7473) provided on 
February 19, 2020. 
 
You asked the Plan to reimburse for the dental services. You say that it was your understanding that the 
procedure completed was of a medical nature and should be covered by the Plan. The Plan denied your request. 
The Plan says this service was provided for the comfort of dentures (a  dental benefit) and is therefore, not a 
medical benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Centers for Medicare and Medicaid Services (CMS) would also consider this primarily dental in nature as both 
the dentist and periodontist medical records reflect that this was done for comfort due to your dentures. 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 reimburse for removal of 
torus mandibularis (D7473) provided on February 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigations and topical application of fluoride 
varnish provided on October 3, 2019. 
 
The enrollee asked the Plan to pay for the gingival irrigations and topical application of fluoride varnish. The 
enrollee said that prior to receiving these services, they contacted the Plan and were assured that these services 
would be covered. The Plan denied the enrollees request. The Plan says these services 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 Plans 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 
gingival irrigations and topical application of fluoride varnish provided on October 3, 2019.