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

 
We decided that the Plan does not have to pay for the laboratory services provided on November 4, 2019 by an 
out of network (OON) provider. 
 
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 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 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 November 4, 
2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided by a 
participating provider on June 9, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you should only have to pay one 
copayment. 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 $35 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $35 copayment for each physical therapy. The total amount you are being asked 
to pay is $70 ($35 + $35 = $70). If you have more than one type of therapy during the same visit, cost-sharing 
will apply to each type; therefore, the correct copayments have been applied. physical therapy falls within the 
outpatient rehabilitation 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 
physical therapy provided by a participating provider on June 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1851) and additions (L2397 and L2385) 
provided on March 31, 2020. 
 
You asked the Plan to pay for the knee orthosis and additions. You say that you would like reconsideration 
because these supplies are medically necessary. The Plan denied your request. The Plan says the documentation 
submitted did not include an itemized shipping/billing invoice to indicate the specific supplies or a proof of 
delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
record does not include an itemized billing/shipping invoice to verify the supplies provided and the delivery 
ticket is for a different date of service than what was billed. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for knee orthosis (L1851) and additions (L2397 and L2385) provided on March 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a behavioral health inpatient admission provided from April 
3, 2020 to April 14, 2020. 
 
You asked the Plan to pay for the behavioral health inpatient admission. The Plan denied your request. The 
Plan says that 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 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 a behavioral health inpatient admission provided from April 3, 
2020 to April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the naturopathic services provided to you on December 4, 
2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for the naturopathic services provided to you on December 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on January 19, 2020 to January 21, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. 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 $225 
copayment per day for days 1 to 6. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $225 copayment per day for days 1 to 2 for an inpatient hospital stay. The total 
amount you are being asked to pay is $450 ($225 x 2 days = $450). 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 provided by a participating provider on January 19, 2020 to January 21, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided on May 
6, 2020. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you were told that 
COVID-19 testing was covered without a 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 $45 
copayment for urgently needed services.  
 
You have been asked to pay a $45 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 May 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services. 
 
You asked the Plan to pay for IRF care. You say that IRF care was medically necessary. The Plan denied your 
request. The Plan says coverage criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is not shown to have required fifteen hours per week of rehabilitative 
services and regular physician evaluation.  The enrollees care needs could have been met at a lower level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay you had from 
February 12, 2020 through February 18, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were in the 
hospital earlier in February and had your appendix removed.  You said you had to return to the hospital 
because they didn't get all of the infection during your previous stay. You said that if the hospital had done the 
job correctly, you wouldn't have had to return to the hospital. The Plan denied your request. The Plan says you 
were charged this copayment 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 $325 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $325 copayment per day for days 1-5 for the inpatient hospital stay. the inpatient 
hospital stay falls within the inpatient hospital care benefit category. This copayment applies regardless of the 
reason for the hospitalization. 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 inpatient hospital 
stay you had from February 12, 2020 through February 18, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Lab
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 January 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 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 January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on May 21, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this was emergency 
treatment for an abscessed tooth causing constant and severe pain. The Plan denied your request. The Plan says 
this service exceeds the frequency limitation in the benefit plan. 
 
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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation on January 21, 2020, and your problem focused limited oral evaluation (D0140) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused 
limited oral evaluation (D0140) provided on May 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from March 9, 
2020 to March 17, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel that you should 
not be charged separate inpatient hospital copayments. 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 $325 
copayment per day for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from March 9, 2020 to March 17, 2020. Therefore, you are responsible to 
pay a $325 copayment for days 1-5 (March 9, 2020 to March 13, 2020). $325 (copayment) x 5 (inpatient days) 
= $1,625.  
 
You have been asked to pay the total copayment amount of $1,625 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 March 9, 2020 to March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 19, 
2019. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges 
because you saw the doctor for 5 minutes and were told that you would not owe a 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 $45 
copayment for specialist visits.  
 
You have been asked to pay a $45 copayment for a specialist visit. A specialist visit 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 copayment for a specialist visit provided on December 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a behavioral health inpatient admission provided from 
February 6, 2020 to February 17, 2020. 
 
You asked the Plan to pay for the behavioral health inpatient admission. 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 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 a behavioral health inpatient admission provided from February 
6, 2020 to February 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for an aspiration or injection of large joint or 
joint capsule (20610) with Hyaluronan or derivative (J7321) performed on June 11, 2020. 
 
You asked the Plan to waive the cost-sharing for an aspiration or injection with Hyaluronan or derivative. You 
say that this cost-sharing is too expensive. The Plan denied your request. The Plan says the correct cost-sharing 
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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $20 copayment for each visit to a specialist and 20% coinsurance for Medicare Part B prescription 
drugs. 
 
The enrollee has been asked to pay a $20 copayment and a $16.53 coinsurance (20% of the Plan-allowed 
amount of $82.64) for an aspiration or injection with Hyaluronan or derivative. An aspiration or injection falls 
within the "Physician/Practitioner services, including doctor's office visits" benefit category. Hyaluronan or 
derivative falls within the "Medicare Part B prescription drugs" 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 cost-sharing for an aspiration or injection of large joint or joint capsule (20610) with 
Hyaluronan or derivative (J7321) performed on June 11, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on May 26, 2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you should not owe a copayment 
for a colonoscopy screening. 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 $175 
copayment for outpatient surgery.  
 
The medical records show that you had a polyp removed during a colonoscopy provided on May 26, 2020. 
Therefore, the colonoscopy is considered diagnostic, not preventative and you are responsible to pay the $175 
copayment.  
 
You have been asked to pay a $175 copayment for a colonoscopy. A colonoscopy 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 a colonoscopy provided on 
May 26, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99285) on 
January 17, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that the emergency room 
visit was a result of prior hospital error and you do not feel you owe the hospital anything. 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 $100 
copayment for each Medicare-covered emergency room visit.  
 
You have been asked to pay a $100 copayment for an emergency room visit. An emergency room 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 
emergency room visit (99285) on January 17, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 4Kscore testing provided on February 29, 2020. 
 
You asked the Plan to pay for 4Kscore testing. You say that this testing is covered by Medicare. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the enrollee did not 
meet the Medicare criteria for 4Kscore testing. 
 
The Plan follows Medicare rules. Medicare rules say that 4Kscore testing is only covered when all of the above 
clinical criteria have been met. 
 
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 4Kscore testing. Our reviewer says that this 
4Kscore testing does not meet the Medicare criteria for coverage. Our physician reviewer found the enrollee 
had a moderately elevated Prostate-Specific Antigen (PSA) level. Testing the enrollee received prior to the 
4Kscore test being ordered is not documented. The lab requisition indicates that the enrollee's PSA level was 
rising rapidly and that he had a strong family history of prostate cancer. As such, a prostate biopsy was 
indicated and the performance of 4Kscore testing was not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4Kscore testing have not been met. Therefore, we decided that the Plan does not 
have to pay for 4Kscore testing provided on February 29, 2020.