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

 
We decided that the Plan does not have to pay for the ambulance services provided on March 29, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated by the medics 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 March 29, 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 March 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CPAP and related supplies provided on May 15, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the CPAP and related supplies. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the items received are not a covered 
benefit when provided by an OON provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The rendering 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 CPAP and related supplies provided on May 
15, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs and does not have 
to waive the copayment for the administration provided on May 5, 2020. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs and to waive the copayment for the 
administration. You say that you disagree with the charges. 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 20% 
coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must 
pay a $20 copayment for specialist services.  
 
You received Medicare Part B drugs on May 5, 2020. The total allowed amount is $3,430.98 and 20% of that is 
$686.19. You are also responsible to pay a $20 copayment for the administration. The total amount you owe is: 
$706.19.  
 
You have been asked to pay the total amount of $706.19 for Medicare Part B drugs and the administration. 
Medicare Part B drugs fall within the Medicare Part B prescription drugs benefit category. The administration 
falls within the physician/practitioner services, including doctor's office visits benefit category.  
 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for Medicare Part B drugs and does not have to waive the 
copayment for the administration provided on May 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the out of network cost share for the porcelain crown (D2740) 
provided on May 14, 2020. 
 
You asked the Plan to pay the out of network cost share for the dental service. You say that the Evidence of 
Coverage states that non-routine dental care required to treat illness or injury may be covered. You say that 
your tooth was injured by a sharp, hard object. You say that it caused illness as you had a 100.4-degree fever. 
You also say that the only in network dentist is an 18 mile ferry ride away from you. The Plan denied your 
request. The Plan says up to $200 for any dental services that are not covered in the preventive services will be 
paid. The Plan says that the benefit period program maximum has been exceeded. The Plan also says when you 
receive these services out of network, you are responsible for the billed amount that exceeds the $200 benefit 
limit. 
 
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 and crowns are listed as covered, the 
$200 maximum benefit has been exceeded. The record shows that the Plan paid $200 towards the crown that 
you received on this date of service. Additionally, the provider in this case is not an in network provider. The 
Evidence of Coverage clearly states that when you receive dental services out of network, you are responsible 
for the billed amount that exceeds the $200 benefit limit.. Therefore, we decided that the Plan does not have to 
pay the out of network cost share for the porcelain crown (D2740) provided on May 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy rendered on July 31, 
2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you would like the amount 
reviewed and/or adjusted. The Plan denied your request. The Plan says the coinsurance 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 a 20% 
coinsurance for Part B covered drugs including Part B covered chemotherapy.  
 
Review of the file shows that you received chemotherapy on July 31, 2020. You have been asked to pay a 20% 
coinsurance for these services. These services fall within the Part B covered drugs including Part B covered 
chemotherapy benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the chemotherapy 
rendered on July 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Warfarin testing (93793) performed on 
June 3, 2020. 
 
You asked the Plan to waive the copayment for Warfarin testing. You say that this charge is unfamiliar to you. 
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 $15 
copayment for each visit for laboratory tests, non-radiological diagnostic tests, flat film X-rays, and 
ultrasounds.  
 
You have been asked to pay a $12.12 copayment for Warfarin testing. Warfarin testing falls within the 
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have 
been asked to pay less than the full 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 Warfarin testing (93793) performed on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 20, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the debridement (11042). You say that these services were rendered before 
obtaining authorization to avoid a delay in care. The Plan denied your request. The Plan says the 
documentation reflects that this was not emergency care and there are network providers available. 
 
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 March 20, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided on April 
9, 2020. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you should only owe a 
primary care provider 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 $40 
copayment for urgently needed services.  
 
You have been asked to pay a $40 copayment for urgently needed services. Urgently needed services fall 
within the urgently needed 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 
urgently needed services provided on April 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing provided to the enrollee on March 31, 2020. 
 
You asked the Plan to pay for this testing. You say that this testing should be covered by the Plan. The Plan 
denied your request. The Plan says The Plan says this is an administrative determination for coding and is not 
based on clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 
requires use of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative 
field. 
 
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 claim is missing the main code 
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of 
this claim have not been met. Therefore, we decided that the Plan does not have to pay for testing provided to 
the enrollee on March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam rendered on May 28, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that the services were for an annual 
visit and should have no copayment. The Plan denied your request. The Plan says the copayment 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 a $40 
copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye, including an annual 
glaucoma screening for members at high risk.  
 
Review of the file shows that you received an eye exam on May 28, 2020. You have been asked to pay a $40 
copayment for these services. These services fall within the Medicare-covered exams to diagnose and treat 
diseases of the eye, including an annual glaucoma screening for members at high risk 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 the eye exam rendered on May 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for pathology services provided by a 
participating provider on June 4, 2020. 
 
You asked the Plan to waive the copayment for pathology services. You say that you do not agree with this 
copayment. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for outpatient diagnostic tests/laboratory tests.  
 
You have been asked to pay a $10 copayment for pathology services. Pathology services fall within the 
outpatient diagnostic tests/laboratory tests 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 pathology services provided by a participating provider on June 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate upper denture (D5130), the immediate lower 
denture (D5140), and the prosthodontic services (D5899 x 2) provided bon October 31, 2019 by an out of 
network dentist. 
 
You asked the Plan to pay for the dental services. You say that you did not know this type of dentures would 
not be covered. You also say that some type of denture coverage would be fair. The Plan denied your request. 
The Plan says the provider in this case is not a network provider. 
 
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, dental services that you receive out of 
network are not covered. Therefore, we decided that the Plan does not have to pay for the immediate upper 
denture (D5130), the immediate lower denture (D5140), and the prosthodontic services (D5899 x 2) provided 
bon October 31, 2019 by an out of network dentist.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a Vertiflex interspinous device (22870). 
 
You asked the Plan to pre-approve a Vertiflex interspinous device. You say that you believe that this procedure 
for this enrollee at this time does meet the Medicare requirements for medical necessity. The Plan denied your 
request. The Plan says the request for the placement of the interspinous spacer device is considered 
experimental. More research is needed to show safety and efficacy of this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Vertiflex interspinous device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of a Vertiflex interspinous device (22870).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 8, 2020, by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that you would like reconsideration because the services were 
medically necessary. The Plan denied your request. The Plan says this provider is not under contract with the 
Plan. 
 
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 8, 2020, by 
an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy services coded 45380 provided on March 4, 
2020. 
 
You asked the Plan to pay for the colonoscopy services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 45380 
for the colonoscopy services has a bundled relationship with code 45385 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 the colonoscopy services coded 45380 
provided on March 4, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ER visit provided on February 2, 2020. 
 
You asked the Plan to waive the copayment for an ER visit. You say that the staff did little to help your pain 
and you disagree with the charges. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency care 
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 ER visit provided on 
February 2, 2020.  
 
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit 
MAXIMUS to make a decision on this type of complaint.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT Scans (70450 and 74176) and x-ray (71045) provided 
on November 16, 2019. 
 
You asked the Plan to pay for the CT Scans and x-ray. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the provider needs to bill Original 
Medicare, using the proper modifiers, for services rendered on November 16,2019. 
 
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 CT Scans (70450 and 74176) and x-ray (71045) provided 
on November 16, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for lab tests provided on June 11, 2020. 
 
You asked the Plan to waive the coinsurance for lab tests. You say that you had no choice which lab the 
provider sent the sample to and feel that you should not be held responsible for the out-of-network charges. 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 30% 
coinsurance for out-of-network lab tests.  
 
You received lab tests on June 11, 2020, from an out-of-network provider. Therefore, you are responsible to 
pay your share of the out-of-network cost-sharing charges. The allowed amount is $193.25 and 30% of that is 
$57.98. 
 
You have been asked to pay the total coinsurance amount of $57.98 for lab tests. Lab tests fall 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 coinsurance for lab tests provided on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on October 25, 2019. 
 
You asked the Plan to pay for dental services. You say that you believed that there would be coverage for 
these services, and feel it is not fair because the Plan originally paid but then reversed payment. The Plan denied your request. The Plan says the denial of payment for these services is correct. 
 
Medicare generally does not cover dental services. However, the Plan offers supplemental benefits that 
exceed Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does cover 
dental services; however, these services must be obtained from an eligible provider. The Plan does not cover dental services received from a provider who has opted out of Medicare or has been excluded from Medicare coverage.
 
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 dental services provided on October 25, 2019.