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

 
We decided that the Plan does not have to waive the cost sharing for the ambulance services provided by an in-
network provider on May 10, 2022. 
 
You asked the Plan to waive the cost sharing for the ambulance services. You say that you feel that this cost 
sharing amount is too high. 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. Your 
contract with the Plan says that you must pay the full amount for most covered services until you have paid 
your $400 deductible, and the deductible applies to all in and out-of-network services, besides emergency 
services, all Medicare zero-cost preventative services, and urgent care services. Your contract with the Plan 
also says that you must pay a 2% coinsurance of the approved amount, after your $400 deductible is paid, for in 
and out-of-network ambulance services. 
 You have been asked to pay a cost share of $403.12 for the ambulance services ($555.85 total allowed amount 
- $400 deductible = $155.85) ($155.85 x .02 = $3.12) ($400 deductible + $3.12 coinsurance = $403.12). The 
item or service you asked the Plan to waive the cost sharing for falls within the ambulance services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 
deductible which applies to ambulance services. This cost sharing is a contractual obligation that had not been 
met at the time the ambulance services were received on May 10, 2022. Therefore, we decided that the Plan 
does not have to waive the cost sharing for the ambulance services provided by an in-network provider on May 
10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on November 16, 
2022. 
 
You asked the Plan to waive the copayment for eye exam. You say that if the services are covered under the 
plan benefits, then it should not be relevant if the provider does not accept Medicare. The Plan denied your 
request. The Plan says the provider has opted out of Medicare; therefore, no payment can be made. 
 
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 who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to waive the 
copayment for an eye exam provided on November 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a spinal magnetic resonance imaging 
(MRI) provided on November 10, 2022. 
 
You asked the Plan to waive the copayment for a spinal magnetic resonance imaging (MRI). You say that you 
would not have went to an outpatient hospital if you would have known there was a 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 $110 
copayment for advanced imaging services, including an MRI at an outpatient hospital facility. 
 
You have been asked to pay a $110 copayment for a spinal magnetic resonance imaging (MRI). This 
item/service falls within the advanced imaging services, including an MRI at an outpatient hospital facility 
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 spinal magnetic resonance 
imaging (MRI) provided on November 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 10, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on August 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for laboratory services provided on August 4, 
2022. 
 
You asked the Plan to reduce the deductible for laboratory services. You say that this price is too high for 
simple blood work. 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. Your 
contract with the Plan says that there is a $450 in-network deductible which applies to in-network Medicare-
covered lab services. The contract also says that there is a $10 copayment per day, per provider, for Medicare-
covered lab services, after the deductible is met. 
 
The item or service you asked the Plan to reduce the deductible for falls within the outpatient diagnostic tests 
and services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $450 in-network deductible which applies to in-network Medicare-covered lab services. This cost 
sharing is a contractual obligation that had not been met at the time laboratory services was received on August 4, 2022. Therefore, we decided that the Plan does not have to reduce the deductible for laboratory services 
provided on August 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychological/neuropsychological testing  
 
You asked the Plan to pre-approve psychological/neuropsychological testing (codes 96136 x 1, 96137 x 4). 
You say that psychological/neuropsychological testing is medically necessary to evaluate your neurocognitive 
impairment due to intractable epilepsy. The Plan denied your request. The Plan says 
psychological/neuropsychological testing (codes 96136 x 1, 96137 x 4) does not meet the Medicare coverage 
criteria. 
 
The Plan follows Medicare rules. 
 
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 psychological/neuropsychological 
testing (codes 96136 x 1, 96137 x 4). Our reviewer says that psychological/neuropsychological testing  
(codes 96136 x 1, 96137 x 4) is not medically necessary. Our physician reviewer found that you were 
diagnosed with Major Neurocognitive Disorder, Unspecified without Behavioral Disturbance, Major 
Depressive Disorder, Recurrent Episodes, Moderate, Generalized Anxiety Disorder with Panic Attacks and rule 
out PTSD. The medical documentation shows that you claim having memory impairment although there is no 
documentation to the stability of the requesting additional neuropsychological testing. Utilizing the criteria 
from the Medicare LCD L33632 that this testing is intended to diagnose and characterize the neurocognitive 
effects of medical disorders that impinge directly on or indirectly on the brain including detection of neurologic 
disease based on quantitative assessment of neurocognitive abilities, differential diagnosis between 
psychogenic and neurogenic syndromes, delineation of neurocognitive effects of central nervous system 
disorders, neurocognitive monitoring of recovery or progression of central nervous system disorders or 
assessment of neurocognitive function for the formulation of rehabilitation and/or management strategies among individuals with neuropsychiatric disorders, you do not meet the criteria as you are not showing severity 
of symptoms that would warrant additional diagnostic treatment and not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychological/neuropsychological testing (codes 96136 x 1, 96137 x 4) have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the 
psychological/neuropsychological testing (codes 96136 x 1, 96137 x 4).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
August 21, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. 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 $85 
copayment for emergency care. 
 
You have been asked to pay a $85 copayment for emergency room services. This item/service 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 emergency room services 
provided on August 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an in-network procedure and physical 
therapy provided from January 26, 2021, to January 29, 2021. 
 
You asked the Plan to waive the copayments for an in-network procedure and physical therapy. You say that 
you are being charged too much for these services and want this reviewed. 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 $300 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient 
facility, and a $15 copayment for each Medicare-covered physical, occupational, or speech language therapy 
visit ($300 + $15 = $315 total).  
 
You have been asked to pay a $315 total copayment for an in-network procedure and physical therapy.  This item/service falls within the Medicare-covered outpatient surgery in an ambulatory surgical center or 
hospital outpatient facility and Medicare-covered physical, occupational, or speech language therapy 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 copayments for an in-network procedure and 
physical therapy provided from January 26, 2021, to January 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the drug administration services provided 
by an in-network provider from November 7, 2022, to November 11, 2022. 
 
You asked the Plan to waive the copayment for the drug administration services. You say that you were not 
told that there would be a copayment applied to these services. 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 $325 
copayment for in-network Medicare-covered outpatient hospital facility surgery services. 
 
 
 
 
 You have been asked to pay a $1041.45 copayment for the drug administration services because the allowed 
amount for each service is less than the $325 copayment ($208.29 allowed amount x 5 services = $1041.45).  
These items/services fall 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 the drug administration services provided by an in-network provider from November 7, 2022, to November 
11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 01, 2022. 
 
You asked the Plan to pay for an office visit. You say that you were not aware that this provider was out-of-
network. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 82465 billed for date of service February 26, 
2021. 
 
You asked the Plan to pay for procedure code 82465. You say that you have submitted medical records to 
support payment. The Plan denied your request. The Plan says payment for code 82465 is bundled into 
payment for code 80061. 
 
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, we have confirmed that code 82465 
is a column II code to column I code 80061 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 82465 billed for date of service February 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on October 05, 2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary or rest home 
visit provided on October 05, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) on 
September 23, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you want to appeal the amount being 
charged. 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 $350 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds. You will 
only pay one copayment per day even if multiple diagnostic radiology services are performed. Covered 
services include, but are not limited to diagnostic radiology services, such as ultrasound, nuclear cardiac 
imaging, PET, MRI, and CT scan. The provider billed in the amount of $1,650 and the allowed amount is 
$167.94. This is less than the copayment amount. Therefore, results in the total cost sharing amount of $167.94. 
 You have been asked to pay a $167.94 copayment, which is less than the copayment for MRI. This item/service 
falls within the outpatient diagnostic tests 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 magnetic resonance imaging (MRI) on September 23, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied
your request. The Plan says that Medicare coverage criteria were not met. Maximus upheld the Plans decision.
Maximus then reopened the case as you were not given an opportunity to present additional information before
the case was closed as you had specifically requested an extension.
Our Medical Director looked at the case file and the additional medical records you submitted with your
request on March 7, 2023. At issue is coverage for IRF services. The enrollee is s 76-year-old man with
multiple medical problems that include heart disease, hypertension, DVT, nasopharyngeal cancer, Hodgkin's
lymphoma, and invasive squamous cell carcinoma of the lung, for which he underwent a right lower lobectomy
on January 26, 2023. The enrollee has a diagnosis of respiratory failure, unspecified with hypercapnia.
On February 24, 2023, the enrollee had was unable to perform daily activities or ambulate without severe
desaturations due to poor activity tolerance and decreased endurance. On March 1, 2023, the enrollee's level of
function was grossly contact-guard, and limited endurance and dyspnea. He walked 30-45m, but cadence was
slow and shuffling, base of support was narrow, and respiratory fatigue required a rest break. The enrollee's
physician documents that the enrollee will require intensive therapy interventions of no less than 3 hours per
day, 5 days per week, and that he will be able to tolerate the demands of such a program and make good
progress.
Our Medical director concluded the additional documentation supports that the complexity of the enrollee's
nursing, medical, and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care.
The documentation also supports that the enrollee requires treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. At this time there is
a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
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 been met. Therefore, we decided that the Plan has to pre-approve
acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 01, 2022. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
September 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014) and an eye refraction 
(92015) provided on October 17, 2022. 
 
You asked the Plan to pay for a medical eye examination (92014) and an eye refraction (92015). You say that 
you were not aware that your doctor of 15 years was not in the network when the services were done. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a medical eye 
examination (92014) and an eye refraction (92015) provided on October 17, 2022.