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

We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from February 27, 2020 to March 4, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan denied your request. The Plan says that the care needs could have been provided in an alternative care level, such as observation status, or acute nursing facility. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 
 
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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for inpatient hospital services provided to the enrollee from February 27, 2020 to March 4, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services provided on December 19, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the office visit (99213). You say that you would like reconsideration because the 
member presented with only their Medicare ID card. The Plan denied your request. The Plan says utilization of 
network providers is required when possible and 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 December 19, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $960 copayment charged for skilled nursing facility service provided from October 1, 2019 to October 16, 2019.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. You say that you do not realize the previous days you used were included in that first 20-day benefit. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.
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 $160 per day for days 21 to 57 of a skilled nursing facility stay. 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 $960 copayment charged for skilled nursing facility service provided from October 1, 2019 to October 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397) 
provided to the enrollee on February 25, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary. 
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 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 knee orthosis (L1833) and 
suspension sleeve (L2397) provided to the enrollee on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on November 25, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network 
deficiency for these services. 
 
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 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 medical services provided to the enrollee by an out-of-network provider 
on November 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 12, 2020 to January 15, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because the inpatient hospital stay was necessary. 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 $275 copayment per day for days 1-7 for inpatient hospital care. You had an inpatient hospital stay from January 12, 2020 to January 15, 2020. Therefore, you are responsible to pay a $275 copayment for days 1-3 (January 12, 2020 to January 14, 2020). $275 (copayment) x 3 (inpatient days) = $825. You have been asked to pay the total copayment amount of $825 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 inpatient hospital stay from January 12, 2020 to January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup provided on February 25, 2020. 
 
You asked the Plan to pay for the core buildup. You say that you were informed the dentist was in-network. 
You say that you can't do a crown if you don't do the buildup. The Plan denied your request. The Plan says the 
service is not a covered 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. 
 
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 core 
buildup provided on February 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pacemaker evaluation provided on 
January 3, 2020. 
 
You asked the Plan to waive the copayment for the pacemaker evaluation. You say that you are appealing this 
claim. The Plan denied your request. The Plan says that 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $35 copayment for diagnostic procedures and tests at an in-network specialist's office. For this date 
of service, you have been asked to pay the allowed amount of the claim because this amount is less than the 
$35 copayment for the pacemaker evaluation. 
 
The enrollee has been asked to pay a $31.77 copayment for the pacemaker evaluation. The pacemaker 
evaluation falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the pacemaker evaluation provided on January 
3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for cardiac loop evaluations and specialist 
services provided from January 5, 2020 to March 16, 2020. 
 
You asked the Plan to waive this cost share. You say that these services should be no charge and you did not 
even see a physician. The Plan denied your request. The Plan says the outpatient heart evaluations are actually 
being assessed at a lower copayment than the contract agreement. The specialist services or reading or review 
of the results of the testing do not require you to be present. 
 
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 cost 
share for each service provided. 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 share for cardiac loop evaluations and 
specialist services provided from January 5, 2020 to March 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 19, 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 March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests and a specialist 
office visit provided by a participating provider on January 15, 2020 to February 26, 2020. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests and a specialist office visit. You say 
that you would like to appeal these copayments. The Plan denied your request. The Plan says the correct 
copayments have 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 $30 
copayment for outpatient diagnostic tests/network/diagnostic procedures/tests and a $35 copayment for 
physician/practitioner services/network/specialist.  
 
You have been asked to pay a $30 copayment for each outpatient diagnostic tests and a $35 copayment for a 
specialist office visit. The total amount you are being asked to pay is $95 ($30 + $30 + $35 = $95). Outpatient 
diagnostic tests falls within the outpatient diagnostic tests/network/diagnostic procedures/tests benefit category.  
 
 
 
 
 
A specialist office visit falls within the physician/practitioner services/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 outpatient diagnostic tests and a specialist office visit 
provided by a participating provider on January 15, 2020 to February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on September 12, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
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 September 12, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on June 1, 2020. 
 
You asked the Plan to waive the copayment for an ER visit. You say that the ER visit is due to a technicians 
error 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 June 1, 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on August 13, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 August 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for the Xolair provided on 
April 2, 2019. 
 
You asked the Plan to waive the deductible and coinsurance for the Xolair. You say that this was submitted 
incorrectly. The Plan denied your request. The Plan says that the claim processed correctly. 
 
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 a $500 deductible for out-of-network (POS) medical services and a 
20% coinsurance for each Medicare covered Part B drug.  
 
The Xolair you asked the Plan to waive the deductible and coinsurance for falls within the benefit category out-
of-network (POS) medical services and Medicare covered Part B drug. You have been asked to pay a $500 
deductible and a 20% coinsurance for the Xolair. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $500 deductible for out-of-network (POS) medical services. This cost sharing is a 
contractual obligation that had not been met at the time the Xolair was received on April 2, 2019. Therefore, 
we decided that the Plan does not have to waive the deductible and coinsurance for the Xolair provided on 
April 2, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the vascular ultrasound you received on April 
17, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that the services were previously 
covered. The Plan denied your request. The Plan says the claim was processed 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 $25 
copay for carotid or peripheral vascular ultrasound.  
 
You have been asked to pay a $25 copay for the services provided. The services within the outpatient 
diagnostic 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 copay for the vascular ultrasound you 
received on April 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the air ambulance service provided on February 
28, 2020. 
 
You asked the Plan to reimburse you for the air ambulance service. You say that the Plan told you there would 
only be a copayment of $245 for the air ambulance service. The Plan denied your request. The Plan says the 
enrollee was not transported to the nearest appropriate facility. 
 
The Plan follows Medicare rules. The rules say that transportation from one hospital to another hospital is 
covered only if the hospital to which the patient is transferred is the nearest one with appropriate facilities. 
 
We looked at the file and Medicare rules. There is no documentation submitted to show that the transferring 
hospital did not have adequate facilities to provide the necessary medical care. The enrollee was transported 
back to the U.S. not the nearest appropriate facility. Based on this information, we decided that Medicare rules 
for coverage of the air ambulance service have not been met. Therefore, we decided that the Plan does not have 
to reimburse you for the air ambulance service provided on February 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on May 
21, 2019. 
 
You asked the Plan to pay for the drug testing. 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 supported by the documentation. 
 
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 codes 80307 and G0482 are not supported in the medical record. Specifically, the 
documentation does not support any evidence of an established relationship between the enrollee and the 
ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 
and G0482 provided on May 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services (0370, 70553, J2704, J7120) provided 
on December 17, 2019. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not pre-authorized or emergent. There were 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 radiology services (0370, 70553, J2704, 
J7120) provided on December 17, 2019.