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

We decided that the Plan does not have to pay for office visit services provided to the enrollee on March 17,
2020
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Medicare rules say that health plans can require enrollees to get care from network providers.
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 office visit services provided to the enrollee on
March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visits provided from 
February 10, 2020 to March 5, 2020. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that these specialist office 
visits were post-surgery visits and should be covered. 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 $30 
copayment for each covered in-network specialist visit (including office visits to psychologist and 
psychiatrists).  
 
You have been asked to pay a $30 copayment for each of the specialist office visits. the specialist office visits 
fall within the each ?Physician/Practitioner services, including doctor?s office visits? benefit category. The 
record shows your surgery on January 28, 2020 had a 10-day global period and the specialist office visits were 
outside this global period.  
 
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 the specialist office visits provided from February 10, 2020 
to March 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost for outpatient hospital services and self-administered
drugs provided on December 24, 2019.
You asked the Plan to pay the full cost for outpatient hospital services and self-administered drugs. You say
that this was approved so you should have a lower payment. The Plan denied your request. The Plan says this
processed correctly.
The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the
patients who take them. 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 50% coinsurance after the $950 yearly deductible for out-of-network hospital services
besides mental health, substance abuse, and preventative services.
You have been asked to pay a $10.80 for self-administered drugs that are not covered under Medicare Part B.
You have also been asked to pay the remaining $148.74 of your yearly deductible. The remaining allowed
amount for these services is $6525.25, and 50% of this amount is $3262.63, for a total responsibility of
$3422.18. 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 pay the full cost for outpatient hospital services and self-administered
drugs provided on December 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that on the date of service your wife contacted a 
Plan nurse because of the symptoms you were exhibiting, and she was advised to call 911 immediately. When 
the emergency responders arrived, they checked you over and said you needed to get care at a hospital. You say 
that since they were not able to take you to your primary hospital, your wife took you there instead. You stated 
that you know from prior experience that if you had gone to a non-primary hospital it would have resulted in 
additional costs to then be taken to your primary hospital. You say that you have now received a bill for the 
services, and you asked the Plan to reconsider providing coverage. 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 February 25, 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.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90834) provided 
December 7, 2019 to January 25, 2020. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary and were beneficial. The Plan denied your request. The Plan says the provider at issue is not eligible 
for Medicare payment. 
 
The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselors (LPC's) are 
not eligible for enrollment in the Medicare program.  
 
We looked at the file and Medicare rules. The provider in this case was a Licensed Professional Counselor and 
therefore is not eligible for Medicare payment. Based on this information, we decided that Medicare rules for 
coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does 
not have to pay for outpatient mental health services (90834) provided December 7, 2019 to January 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye examination provided on February 
27, 2020. 
 
You asked the Plan to waive the copayment for eye exam. You say that you did not get a refraction done at this 
visit and do not feel you should have to pay a copayment. The Plan denied your request. The Plan says the 
copayment amount you are being charged is correct. 
 
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 $35 
copayment for diagnostic eye exam.  
 
You have been asked to pay $35 copayment for eye exam. Eye exam falls within the Vision 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 eye examination provided on February 27, 
2020.  
 
Your complaint regarding your experience with this provider is considered to be a grievance. MAXIMUS 
Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more 
information about your grievance
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the train-of-four (TOF) testing provided on December 11, 
2019 billed with unlisted code 95999. 
 
You asked the Plan to pay for the TOF testing. You say that this was correctly billed since there is no official 
CPT code for TOF testing. The Plan denied your request. The Plan says this is 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. Separate reporting/payment of services which 
are integral to other procedures is not allowed. 
 
In this case, TOF testing is an integral part of intraoperative neuromonitoring. As such, billing separate for this 
component of the service is not appropriate. Therefore, we decided that the Plan does not have to pay for the 
train-of-four (TOF) testing provided on December 11, 2019 billed with unlisted code 95999.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 12, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the enrollee was looking to establish a primary care 
physician. You say that you would like this claim reprocessed and approved for payment. 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 an office visit provided on December 12, 2019 by 
an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for destruction of skin growth provided by a 
participating provider on March 2, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you did not have a surgery 
done. 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 $295 
copayment for outpatient surgery.  
 
You have been asked to pay $137 which is less than your copayment amount of $295 for an outpatient surgery. 
The skin growth removal is considered an outpatient surgery; therefore, the correct copayment has been 
applied. An outpatient surgery falls within the outpatient surgery 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 destruction of skin growth provided by a participating provider on March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 12, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z Code identifier should be entered adjacent in the 
comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on February 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 24, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 laboratory services provided on February 24, 
2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice long term care services (code T2046) provided 
from August 1, 2019 to August 31, 2019. 
 
You asked the Plan to pay for the long term care services. You say that when you entered authorization 
information, it stated that authorization was not required for this service. The Plan denied your request. The 
Plan says the denial of payment for these services is correct, because the billed code is not valid for Medicare 
purposes and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code T2046 is not valid for Medicare 
purposes and is not payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the long term care services have not been met. Therefore, we decided that the Plan does not have to 
pay for the hospice long term care services (code T2046) provided from August 1, 2019 to August 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on February 28, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you've never been charged for 
this before. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for physician/practitioner services/specialist services.  
 
You have been asked to pay a $20 copayment for specialist services. The correct copayment has been applied 
to the services provided. Specialist services fall within the physician/practitioner services/specialist 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 specialist services provided by a 
participating provider on February 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that on the date of service, you were at dinner 
when you lost consciousness for almost 10 minutes. You say that the facility was alarmed and so they called 
911. When the responders arrived, they evaluated you and checked your vitals. You stated that they 
recommended you be transported to the hospital, however after running some tests they determined that you 
could go home. You say that they advised you to follow up with your treating physician. You asked the Plan to 
reconsider providing coverage for the ambulance services. 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 December 13, 2019. 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, spine, single view, specify level 
(72020) provided to the enrollee on January 17, 2020. 
 
You asked the Plan to pay for the imaging. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The documentation submitted did not include a radiology report documenting a radiologic examination, spine, 
single view, specify level, was performed on the billed date of service;  therefore, the billed CPT code 72020 
cannot be verified. It should be noted that multiple attempts were made to obtain additional information from 
the provider. Based on this information, we decided that Medicare rules for coverage of the imaging have not 
been met. Therefore, we decided that the Plan does not have to pay for radiologic examination, spine, single 
view, specify level (72020) provided to the enrollee on January 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from January 21, 2020 to 
January 31, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
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 
physician's 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 physician's services provided from January 21, 2020 to 
January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON medical services. You say that the records support that this was a medically necessary visit. The Plan denied your request. The Plan says these services were provided OON without obtaining authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. 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 February 28, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90791, 90837) provided 
September 3, 2019 to December 10, 2019. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this provider is not eligible for Medicare payment. 
 
The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselors (LPC?s) are 
not eligible for enrollment in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue is a LPC and therefore is not eligible for 
Medicare Payment. Based on this information, we decided that Medicare rules for coverage of the outpatient 
mental health services have not been met. Therefore, we decided that the Plan does not have to pay for 
outpatient mental health services (90791, 90837) provided September 3, 2019 to December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) and the chronic 
care management services rendered by the out of network (OON) provider on December 10, 2019. 
 
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 has network providers available 
who can provide 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 domiciliary or rest home visit (99336) and the chronic care management services 
rendered by the out of network (OON) provider on December 10, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
March 28, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the treating physician ordered this testing to 
determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing should be billed with CPT code 
81479 for date of service March 28, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile (CGP) testing provided on March 28, 2020.