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

We decided that the Plan does not have to pay for the CGP testing provided on January 30, 2020. You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed incorrectly. The Plan must follow Medicare rules. Medicare rules say that CGP testing must be reported with one unit of CPT 81479 and the appropriate DEX Z-Code. We looked at the file and Medicare rules. The requested CGP testing was billed with multiple CPT codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the CGP testing provided on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on January 10, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 out of network physician services provided to the enrollee on January 10, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on October 22, 
2019. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you have met your maximum out-
of-pocket amount for 2019 and you should not be responsible for any copayment amount. 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 an $80 
copayment for each diagnostic radiology service.  
 
You have been asked to pay an $80 copayment for the ultrasound. The ultrasound falls within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. The record shows that you had not yet 
met your maximum-out-of-pocket amount on this date of service.  
 
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 ultrasound provided on October 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71046) provided on October 15, 2019.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request. The Plan says this is an exact duplicate of another service that has been approved and paid.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We find that CPT code 71046 is not supported in the record. Specifically, the record does not show that multiple chest x-rays were rendered on this date of service. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71046) provided on October 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care from April 25, 2020 
through May 1, 2020 provided by an in-network provider. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you have had hospital 
admissions before and they never cost this much. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you were admitted on April 25, 2020 and discharged on May 1, 2020. You were 
asked to pay a $360 copayment per day from April 25, 2020 through April 29, 2020, days 1-5 of your inpatient 
stay. There were no copayment charges from April 30, 2020, day 6 of your inpatient hospital care until your 
day of discharge May 1, 2020. Per your contract there is a $360 copayment per day required for days 1-5 for in-
network inpatient hospital care. 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 inpatient hospital care from 
April 25, 2020 through May 1, 2020 provided by an in-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGP testing provided on February 13, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be reported with one unit of 
CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested CGP testing was billed with multiple CPT codes. Per 
the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-Code. Based 
on this information, we decided that Medicare rules for coverage of the testing have not been met. 
 Therefore, we decided that the Plan does not have to pay for the CGP testing provided on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dexcom G5 continuous glucose monitor and supplies.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation does not indicate that you check your blood glucose four or more times per day, or require insulin injections three or more times per day.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are noted to be a type II diabetic who uses an oral medication to treat her diabetes. How frequently you test your blood glucose is not documented. There is no evidence that you use the results of blood glucose testing to self-adjust the dosage of insulin multiple times per day. Therefore, the documentation does not support that the use of a CGM is medically necessary or reasonable. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Dexcom G5 continuous glucose monitor and supplies.
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 the ambulance was called for the enrollee 
because the enrollee had experienced a fall. You stated that the ambulance did not transport the enrollee. You 
say that the enrollee's nursing home has a rule that emergency services must be called if a patient falls. 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 June 16, 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 waive the copayment for a duplex scan provided by a participating
provider on May 7, 2020.
You asked the Plan to waive the copayment for a duplex scan. You say that you were told that you shouldn't
have to pay for the over charge. 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 $50
copayment for outpatient diagnostic tests/in-network/diagnostic procedures and tests.
You have been asked to pay a $50 copayment for a duplex scan. The correct copayment has been applied to the
services that were provided. A duplex scan falls within the outpatient diagnostic tests/in-network/diagnostic
procedures and 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 a duplex scan
provided by a participating provider on May 7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a nuclear stress test provided by a
physician on May 12, 2020.
You asked the Plan to waive the copayment for a nuclear stress test. You say that you pay more since you've
been retired than when you worked. 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 $225
copayment for outpatient diagnostic tests/advanced imaging service.
You have been asked to pay a $225 copayment for a nuclear stress test. The correct copayment has been
applied to the services that were provided. A nuclear stress test falls within the outpatient diagnostic
tests/advanced imaging service 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
nuclear stress test provided by a provider on May 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 30, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot
be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for the drug testing services provided on October 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient hospital clinic visit and duplex
scan provided on November 8, 2019.
You asked the Plan to waive the deductible for clinic visit and diagnostic test. You say that you had met the
deductible before this service, so the Plan should pay this outstanding balance. The Plan denied your request.
The Plan says the deductible 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. Your
contract with the Plan says that there is $1,000 deductible for out-of-network outpatient clinic visit and
diagnostic test. At the time this claim was processed, $327.19. The allowed amount of this claim is $305.59,
resulting in a deductible obligation of $305.59.
The items or services you asked the Plan to waive the deductible for fall within the benefit category Outpatient
Hospital Services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is
$1,000 deductible for out-of-network outpatient hospital services. This cost sharing is a contractual obligation
that had not been met at the time clinic visit and diagnostic test was received on November 8, 2019. Therefore,
we decided that the Plan does not have to waive the deductible for an outpatient hospital clinic visit and duplex
scan provided on November 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services (88348) provided January 21, 2020. You asked the Plan to pay for the pathology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim is a duplicate. 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 88348 is not supported in the medical record. Specifically, another claim was submitted for the same code on the same date of service. A modifier was not included to note that this was a separate service. Based on this information, we decided that Medicare rules for coverage of the pathology services have not been met. Therefore, we decided that the Plan does not have to pay for pathology services (88348) provided January 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on March 24, 2020. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order. The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on February 19, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that the office visit was
inappropriate and you should not have to pay for it. 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 $50
copayment for physician/practitioner services/in-network/specialist.
You have been asked to pay a $50 copayment for a specialist office visit. The correct copayment has been
applied to the services that were provided. A specialist office visit falls within the physician/practitioner
services/in-network/specialist 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 specialist
office visit provided on February 19, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the piperacillin sodium/tazobactam
sodium injections and lorazepam injection provided from February 19, 2020 to February 22, 2020.
You asked the Plan to waive the coinsurance for these drugs. The Plan denied your request. The Plan says that
you are responsible for the coinsurance.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for Medicare Part B drugs and chemotherapy drugs at a physician's office, a pharmacy, or at a
hospital facility as an outpatient service.
You have been asked to pay a 20% coinsurance for these drugs. These drugs fall within the Medicare Part B
drugs and chemotherapy drugs at a physician's office, a pharmacy, or at a hospital facility as an outpatient
service 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 piperacillin
sodium/tazobactam sodium injections and lorazepam injection provided from February 19, 2020 to February
22, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 22, 2020 
to February 12, 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 service is 
not medically necessary. 
 
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 January 22, 2020 to February 12, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve an office visit. You say that you are asking for a new doctor because you are 
having an issue with the retinal office. The Plan denied your request. The Plan says you do not have out-of-
network benefits. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction provided on March 10, 2020. 
 
You asked the Plan to pay for the extraction. You say that this service was medically necessary. You also say 
that you are on a limited income. The Plan denied your request. The Plan says the maximum allowed for your 
quarterly max of the first quarter had been met. 
 
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 Plan offers up to a $450.00 
allowance for comprehensive dental services every quarter. The record shows that you met the quarterly 
allowance on February 24, 2020 and your quarterly allowance had been exhausted. Therefore, we decided that 
the Plan does not have to pay for the extraction provided on March 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost shares for the outpatient surgery services provided on 
April 28, 2020. 
 
You asked the Plan to waive the cost shares for the services provided. You say that you cannot afford the 
charges. The Plan denied your request.  
 
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 each outpatient hospital facility visit, including physician or surgical charges.  
 
You have been asked to pay a 20% coinsurance for the services provided. The services fall 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 cost shares for the outpatient 
surgery services provided on April 28, 2020.