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

 
We decided that the Plan does not have to waive the copayment for the tangential biopsy of skin (e.g., shave, 
scoop, saucerize, curette) single lesion (11102) provided May 13, 2022. 
 
You asked the Plan to waive the copayment for the procedure. You say that you are requesting a review of the 
decision made by the Plan. You had called and a Plan representative had told you that you were not responsible 
for these charges on the bill. The Plan denied your request. The Plan says the claim was processed with the 
correct cost share applied per the Evidence of Coverage. 
 
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 $345 
copayment for Medicare covered surgery or other services provided at an outpatient hospital, including but not 
limited to hospital or other facility charges and physician or surgical charges. 
 
You have been asked to pay $175.39. The provider had billed $297.00 for the services. The allowed amount 
was $175.39. Since the allowed amount is less than the copayment amount, you are responsible for the lesser amount. The procedure falls within the Outpatient Surgery and Other Medical 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 the tangential biopsy of skin (e.g., shave, scoop, saucerize, curette) single lesion (11102) 
provided May 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has metastatic lung 
neoplasm with progression on a Tencetriq-containing regimen. As he has failed Tecentriq, Keytruda cannot be 
approved. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided on August 24, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 81479 is not supported in the medical record. Specifically, the date of service billed 
does not match the date the specimen was collected (July 13, 2021). Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing (81479) provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 23, 2022. 
 
You asked the Plan to pay for physician's services. 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 physician's services provided on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 16, 2022 billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81328, 81335, 81355, & 
81407. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 16, 2022 billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 
81328, 81335, 81355, & 81407.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on February 9, 2022. 
 
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 procedure code 00400 is not supported. 
 
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 00400 is anesthesia for procedures on the integumentary 
system on the extremities, anterior trunk and perineum; not otherwise specified. 
 
We find that CPT code 00400 is not supported in the medical record. Specifically, there is no documentation to 
support that a second anesthesia procedure for procedures on the integumentary system on the extremities was 
performed. 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 anesthesia services rendered on 
February 9, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided on March 
17, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the claim should be paid. 
The Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as 
it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency department visit (99285) provided on March 
17, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
April 18, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the provider rendered the service based on 
the enrollee's medical condition. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine-transportation mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that the requested service is a medical necessity 
for you. The Plan denied your request. The Plan says rules for coverage for routine transportation have not 
been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 We looked at your request, the records in the case file, and the rules. In this case, you have requested a trip 
exceeding 50 miles of driving distance. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional routine-transportation mileage.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical assessment 
provided on May 30, 2022. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation with medical assessment. The Plan denied 
your request. The Plan says services from non-participating providers are not covered unless preauthorized. 
 
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 
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 a psychiatric diagnostic evaluation with medical assessment 
provided on May 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided on June 08, 
2021, to June 10, 2021. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that did not conset to this treatment 
and feel that you should not have to pay this large copayment. The Plan denied your request. The Plan says this 
cost sharing was charged 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 $740 
copayment for inpatient care. 
 
You have been asked to pay a $740 copayment for an inpatient stay. This item/service falls within the inpatient 
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. 
You have a $370 per day for days 1 to 5 for an inpatient stay. You stayed for two days ($370 x 2 = $740). 
Therefore, we decided that the Plan does not have to waive the copayment for an inpatient stay provided on 
June 08, 2021, to June 10, 2021. 
 Maximus read your letter and knows that you may have a quality of care concern. Maximus 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methylprednisolone. 
 
You asked the Plan to pre-approve Methylprednisolone. The Plan denied your request. The Plan says this drug 
is not covered under the enrollee's Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methylprednisolone.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the dialysis services provided on February 
01, 2022, to March 26, 2022. 
 
You asked the Plan to waive the coinsurance for the dialysis services. You say that you cannot afford the 
coinsurance for all the dates of service. The Plan denied your request. The Plan says this cost sharing was 
charged 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 dialysis services. 
 
You have been asked to pay 20% coinsurance for the dialysis services. This item/service falls within the 
dialysis 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. The file shows a total of 24 visits for dialysis from February 1, 2022, to March 26, 2022. The 
allowed amount for each treatment is $65.52. This amount was applied for 23 of those visits. For the treatment 
on March 22, 2022, the applied coinsurance was onTherefore, we decided that the Plan does not have to waive 
the coinsurance for the dialysis services provided on February 01, 2022, to March 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for walker on April 27, 2022. 
 
You asked the Plan to waive the coinsurance for walker. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 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 a 20% 
coinsurance for durable medical equipment provider. Covered items include, but are not limited to wheelchairs, 
crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a provider for use in the home, 
IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, and walkers. The provider billed 
in the amount is $308.84 and the Plan exclusions is $302.72. $308.84 - $302.72 = $6.12. $6.12 x 20% = $1.22. 
Therefore, results in total cost sharing amount of $1.22. 
 
 
 
 
 You have been asked to pay a 20% coinsurance for walker. Walkers fall within the Durable medical equipment 
(DME) 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 walker on 
April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an orthopedic visit provided on May 16, 
2022. 
 
You asked the Plan to waive the copayment for an orthopedic visit. You say that you were told there would not 
be a copayment for surgical follow up visits. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for an orthopedic visit. This item/service falls within the 
physician/practitioner services, including doctors 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 an orthopedic visit provided on May 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on April 07, 2022, to 
April 13, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 
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 a $275 
copayment per day for days 1 through 6 per benefit period. $0 Copay per day for additional days. Unlimited 
days for Medicare-covered stays. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and 
other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the 
hospital with a doctors order. The day before you are discharged is your last inpatient day.  
 
 The claim was billed for a six-day admission; however, a claim processing error caused only four days to apply 
a cost share. The remaining two-day cost share has been applied to a subsequent hospital admission. $275 x 4 = 
$1,100. Therefore, results in the total cost sharing amount of $1,100. 
 
You have been asked to pay a $275 copayment each day for inpatient hospital stay. 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 
inpatient hospital stay on April 07, 2022, to April 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on April 
04, 2022, to April 28, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you cannot pay these bills. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $240 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $240 copayment for physical therapy visits. This item/service 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 visits provided on April 04, 2022, to April 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy on May 02, 2022, to May 
12, 2022. 
 
You asked the Plan to waive the copayments for physical therapy. You say that you cannot afford this bill. The 
Plan denied your request. The Plan says the cost sharing you are being charged is 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 a $30 
copayment for Medicare-covered Physical Therapy in-person visits. Covered services include physical therapy, 
occupational therapy, and speech language therapy in-person visits. Outpatient rehabilitation services are 
provided in various outpatient settings, such as hospital outpatient departments, independent therapist offices, 
and Comprehensive Outpatient Rehabilitation Facilities (CORFs). There were 4 visits. $30 x 4 = $120. 
Therefore, results in the total cost sharing amount of $120.  
 
 
 You have been asked to pay a $30 copayment for each physical therapy. 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 on May 02, 2022, to May 12, 2022.