Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits provided from 
February 19, 2020 to April 9, 2020. 
 
You asked the Plan to waive the copayments for physical therapy. You say that no one told you that you would 
owe these amounts. The Plan denied your request. The Plan says the copayment amounts you are being charged 
are 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 $40 
copayment for each physical therapy visit. There were 6 visits, resulting in a total copayment obligation of 
$240. 
 
You have been asked to pay $40 copayment for each physical therapy visit. 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 copayments for 
physical therapy visits provided from February 19, 2020 to April 9, 2020.  
 
Your complaint regarding not being told about the cost-sharing for these services 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation provided on June 4, 2020. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you are allowed two oral evaluations per 
year. You say that you didn't have any yet. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is also limited to preventive 
dental benefits. The limited oral evaluation is not considered a preventive oral exam. Therefore, we decided 
that the Plan does not have to pay for the limited oral evaluation provided on June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a routine primary care provider office visit 
(99214) on February 28, 2020. 
 
You asked the Plan to waive the copayment for a routine primary care provider office visit. You say that this 
service was your annual wellness visit and should have a $0 copayment. 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 $5 
copayment for primary care physician visits.  
 
You have been asked to pay a $5 copayment for a routine primary care provider office visit. The provider's 
office classified the visit as a routine office visit and not an annual wellness visit. A routine primary care 
provider office 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 routine primary care provider office visit 
(99214) on February 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram rendered on January 16, 2020.
You asked the Plan to waive the copayment for these services. You say that you should not have a copayment. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for each Medicare-covered diagnostic procedure and test in an outpatient hospital facility.
Review of the file shows that you received a mammogram on January 16, 2020. Per the contract with the Plan, there is a $100 copayment for each Medicare-covered diagnostic procedure and test in an outpatient hospital facility. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $78.26. Given that the allowed amount was less than the $100 copayment, you have been asked to pay $78.26 for these services.
The rules say that Medicare covers one screening mammogram for women aged 40 and older every 12 months. The Plan contract says that a clinical breast exam is covered once every 24 months.
The file shows that you had a clinical mammogram on December 13, 2018 for which the Plan approved and paid. The services on January 16, 2020 were performed fewer than 24 months from the previously covered exam.
Therefore, we decided that the Plan does not have to waive the copayment for the mammogram rendered on January 16, 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 provider. 
 
You asked the Plan to pay for the office visit. You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says you did not request 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 medical services provided on February 28, 
2020 by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgical procedure provided 
on February 20, 2020. 
 
You asked the Plan to waive the copayment for the outpatient surgical procedure. You say that there should not 
be a copayment for the pre-testing visit. The Plan denied your request. The Plan says you were charged this 
copayment correctly for the surgical procedure. 
 
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 $350 
copayment for Outpatient surgery.  
 
You have been asked to pay $350 copayment for the outpatient surgical procedure. the outpatient surgical 
procedure 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 the outpatient surgical procedure provided on February 20, 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 May 18, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you feel that the doctor could 
have used something stronger than Cortisone. 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 services.  
 
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 May 18, 2020.  
 
We note your complaint that the Cortisone injection was not strong enough. Your complaint is a grievance that 
must be answered by the health plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis services provided on 
February 3, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the targeted genomic sequence analysis 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 targeted genomic sequence analysis services 
provided on February 3, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on May 20, 2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. 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 
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 domiciliary or rest home visit provided on May 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on 
August 12, 2019. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for each outpatient surgery visit.  
 
Review of the file shows that you received outpatient surgical services on August 12, 2019. You have been 
asked to pay a $300 copayment for these services. These services fall within the outpatient surgery visit benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on 
August 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on November 18, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. 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 physician services provided on November 18, 
2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0651). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee requires the device. 
The Plan denied your request. The Plan says a documented four-week trial of conservative therapy 
demonstrating failed response to treatment is required. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to conservative therapy including compression bandages, elevation, and 
exercise. 
 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of a documented before and after measurements. Therefore, we decided that the Plan does not have 
to pay for a pneumatic compression device (E0651).
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 from January 17, 2020, to January 31, 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 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 
from January 17, 2020, to January 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services (36415, 80061, 
83036, 84443, 80053, 85025) provided on April 9, 2020. 
 
You asked the Plan to waive the copayment 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 copayment 
has been applied correctly to the services provided. 
 
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 Medicare-covered laboratory tests provided under the Tier 2 benefit.  
 
You have been asked to pay a $20 copayment for the Medicare-covered laboratory services provided under the 
Tier 2 benefit. Your PCP and the facility who rendered the services are not indicated as 'Tier 1' in the provider 
directory; therefore, the Tier 2 benefit has been applied correctly. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the laboratory services (36415, 80061, 83036, 84443, 80053, 85025) provided on April 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for an ambulance transport (A0425, A0429) provided May 27,
2019.
You asked the Plan to pay for the ambulance transport. You say that the services were medically necessary.
The Plan denied your request. The Plan says the service cannot be billed separately.
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 A0425, A0429 is not supported in the medical record. Specifically, Medicare rules state
if an ambulance is used for the transportation of a hospital inpatient to another facility for diagnostic tests or
special treatment the ambulance trip is considered part of the DRG, and not separately billable. The patient was
a hospital inpatient at the time the transport to another facility was provided. Based on this information, we
decided that Medicare rules for coverage of the ambulance transport have not been met. Therefore, we decided
that the Plan does not have to pay for an ambulance transport (A0425, A0429) provided May 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 Plasma-Based Comprehensive Genomic 
Profiling testing provided on April 14, 2020 billed with multiple line items of different CPT codes. 
 
You asked the Plan to pay for the Guardant 360 testing as billed. You say that this should not be denied as 
experimental as this is a proven test which is supported for this patient. The Plan denied your request. The Plan 
says on review, it was found that no payment can be made for this testing because the provider is unbundling 
when there is a single CPT code which describes this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to report the Guardant360 testing, one 
unit of code 81479 should be reported with the appropriate DEX Z-code.  
 
As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 Plasma-Based 
Comprehensive Genomic Profiling testing provided on April 14, 2020 billed with multiple line items of 
different CPT codes.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on 
February 13, 2020. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you have only paid a 
specialist copayment in the past. The Plan denied your request. The Plan says your provider submitted the 
claim as outpatient surgery. 
 
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 Surgery.  
 
You have been asked to pay a $225 copayment for the outpatient surgery. The 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 the 
outpatient surgery provided on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1852). 
 
You asked the Plan to pre-approve the knee orthosis. You say that the brace is medically necessary. The Plan 
denied your request. The Plan says there is no instability or recent injury that would require the brace. 
 
The Plan follows Medicare rules. Medicare rules say that knee orthoses are covered only when medically 
necessary. 
 
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 knee orthosis. Our reviewer says 
that the knee brace is not medically necessary. Our physician reviewer found clinical exam findings are 
consistent with reported imaging evidence of medial meniscus tearing and medial and lateral compartment 
osteoarthritis. The physician chart notes do not document symptoms or clinical exam findings of instability or 
significant deformity. There is no evidence of knee instability due to knee osteoarthritis, recent knee injury, or 
a surgical procedure on the left knee. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a knee orthosis (L1852).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 12, 2019 by a 
non-contracted 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 a non-contracted 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 medical services provided on November 12, 
2019 by a non-contracted provider.