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

We decided that the Plan does not have to pay for the ambulance services provided by you on March 17, 2020.

You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. 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 March 17, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telemedicine visit you had with a 
surgeon on June 23, 2020. 
 
You asked the Plan to waive the copayment for the telemedicine visit. You say that you did not have an actual 
office visit and due to scheduling issues, you couldn't receive further services from this provider. 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 $45 
copayment for specialist services.  
 
You have been asked to pay a $45 copayment for the telemedicine visit. The surgeon is a specialist.  Plan 
documents explicitly state that you are responsible for the specialist copayment if you have a telemedicine visit 
with a specialist.  This copayment applies regardless of whether or not you are physically seen in the office. 
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 telemedicine visit you had with a surgeon on June 23, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital admission you had 
from July 13, 2020 through July 16, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital admission. You say that you don't think 
you should have to pay this because the hospital made a mistake with your care. The Plan denied your request. 
The Plan says you were charged this amount 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 for per inpatient hospital admission.  
 
You have been asked to pay a $325 copayment for the inpatient hospital admission. This cost sharing applies 
regardless of whether or not you were satisfied with the services received. 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 inpatient hospital admission you had from July 13, 2020 through July 16, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided on March 11, 2020. 
 
You asked the Plan to pay for duplex scan. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for this service is correct, because the record does not indicate that 
the enrollee had any signs or symptoms for testing. 
 
The Plan must follow Medicare rules. Medicare rules say that non-invasive vascular studies done for screening 
purposes are not covered by Medicare.  
 
We looked at the file and Medicare rules. The record shows that this duplex scan extremity study was ordered 
solely based on a family history of vascular disease. This testing was performed without signs or symptoms of 
disease and is therefore considered screening in nature. Based on this information, we decided that Medicare 
rules for coverage of duplex scan have not been met. Therefore, we decided that the Plan does not have to pay 
for a duplex scan provided on March 11, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on May 19, 2020. 
 
You asked the Plan to pay for the eye refraction. You say the doctor needed to do a refraction to compare your 
current eyesight and how it was in the past. The Plan denied your request. The Plan says eye refractions are not 
a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and Medicare rules. Medicare does not pay for procedures performed in the course of any 
eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay 
for an eye refraction provided on 
May 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colectomy (44160) provided on September 7, 2019. 
 
You asked the Plan to pay for the colectomy. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the record does not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 44160 is colectomy, partial, with removal of terminal 
ileum with ileocolostomy. 
 
We asked our coder 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 colectomy. Our reviewer says that CPT code 44160 does 
not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report does not 
include colectomy, partial with removal of terminal ileum. The documentation supports a more appropriate 
code for services performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the colectomy have not been met. Therefore, we decided that the Plan does not 
have to pay for the colectomy (44160) provided on September 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for the services provided on May 21, 2020 by 
an out-of-network provider. 
 
You asked the Plan to waive the cost-sharing for the services. You say that the cost-sharing should be waived 
for COVID-19. 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 received radiologic examination, hand; minimum of 3 views (CPT Code 
73130), injection, methylprednisolone acetate, 40 mg (CPT Code J1030) and wrist hand orthosis (CPT Code 
L3908) on date of service May 21, 2020 from an out-of-network. Per the Covid19 National Response Job aid, 
these services are not eligible for this waiving of cost share as Part B drugs, Lab and diagnostic tests 
(radiological and non-radiological) and Durable Medical Equipment/Prosthetics/Supplies/Orthotics are not 
eligible.  The claim was not coded with any diagnosis code (Z03.818 or Z20.828) that was Covid19 related as 
stated in the COVID-19 National Response Job Aid. Therefore, you are asked to pay 20% for the orthosis, 20% 
for the Part B drug and a $14 copayment for the x-ray. 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-sharing for 
the services provided on May 21, 2020 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the 
enrollee on March 6, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that HCPCS code G0483 is not supported in the medical record. Specifically, the documentation 
submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering 
physician) stating exactly what tests are to be performed; therefore, the billed test cannot be supported. 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 drug testing services (HCPCS G0483) provided to the 
enrollee on March 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the eye surgery you had on January 30, 
2020. 
 
You asked the Plan to waive the deductible for the eye surgery. You say that you were not aware of the change 
in deductible when you had this surgery. The Plan denied your request. The Plan says you were charged this 
deductible 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 that applies to outpatient surgery.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
surgery. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible that applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met 
at the time the eye surgery was received on January 30, 2020. Therefore, we decided that the Plan does not 
have to waive the deductible for the eye surgery you had on January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 15, 2020 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 referring provider 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 January 15, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for four X-ray services (73560 and 73600) 
performed on March 9, 2020. 
 
You asked the Plan to waive the copayment for four X-ray services. You say that you have never paid extra for 
X-rays. 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 $14 
copayment for each Medicare-covered standard X-ray service.  
 
You have been asked to pay $56, or a $14 copayment each for 4 X-ray services. X-ray services fall within the 
"Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 four X-ray services (73560 and 73600) performed on March 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 31, 2019 by a non-
Medicare provider. 
 
You asked the Plan to pay for the services. You say that you were told by the Plan that you get a free 
mammogram at a doctor of your choosing. The Plan denied your request. The Plan says the services obtained 
were rendered by a provider who is not under contract with the health plan and are not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the services provided on October 31, 2019 by a non-Medicare provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on April 28, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing (i.e. Guardant-360 and NEXT-Generation) 
requires use of CPT 81479 (for the entire multi-test panel). 
 
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 Comprehensive Genomic Profile (CGP) testing provided to the enrollee on April 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing for the 
enrollee on May 3, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing (i.e. Guardant-360 and NEXT-Generation) 
requires use of CPT81479 (for the entire multi-test panel). 
 
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 Comprehensive Genomic Profile (CGP) testing for the enrollee on May 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on April 23, 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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on April 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mechanical traction therapy (97012) provided on April 3, 
2020. 
 
You asked the Plan to pay for mechanical traction therapy. You say that this was covered for another member. 
The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for mechanical traction therapy (97012) provided on April 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99285) provided on April 
12, 2019. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration 
because the member was seen multiple times on the same date of service. The Plan denied your request. The 
Plan says this is a duplicate claim to another which has previously been processed 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency department visit have not been met. The record indicates that this is a duplicate 
claim to another that has been previously processed and paid by the Plan. The claim does not include any 
modifier to indicate that this was a separately identifiable service. Therefore, we decided that the Plan does not 
have to pay for an emergency department visit (99285) provided on April 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery (66984) performed on 
March 10, 2020. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you pay a high premium for the 
Plan and believe this procedure should be fully covered. 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 per day for outpatient procedures and services.  
 
You have been asked to pay a $100 copayment for cataract surgery. Cataract surgery falls within the 
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers" 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 cataract surgery (66984) 
performed on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ostomy supplies you received from 
March 17, 2020 through April 15, 2020. 
 
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that no cost sharing should 
apply because these are prosthetics, not durable medical equipment. The Plan denied your request. The Plan 
says you were charged this coinsurance 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 20% 
coinsurance for prosthetic devices and related supplies.  
 
You have been asked to pay 20% coinsurance for the ostomy supplies. The ostomy supplies fall within the 
prosthetic devices and related supplies 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 ostomy supplies you received from March 17, 2020 through April 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on 
January 21, 2020. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the 
charges because you were assured that the services would be fully covered. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received Medicare Part B drugs on January 21, 2020. The total allowed amount is $960.57 and 20% of 
that is $192.11. 
 
You have been asked to pay the total coinsurance amount of $192.11 for Medicare Part B drugs. Medicare Part 
B drugs fall within the Medicare Part B prescription drugs 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 Medicare Part B drugs provided on January 21, 2020.