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

 
We decided that the Plan does not have to waive the copayment for genetic testing provided on June 30, 2021. 
 
You asked the Plan to waive the copayment for genetic testing. You say that you have never had to pay for lab 
work before, and that you should not have to pay for this lab work. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing 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 $120 
copayment for specialty genetic testing.  
 
The record shows the lab work you had done is considered specialty genetic testing. You have been asked to 
pay a $120 copayment for genetic testing. Genetic testing falls 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 
genetic testing provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to waive the $40 copayment for an office visit on September 8, 2021.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The
Plan denied your request. The Plan says this copayment was applied as this was not your normal primary care
group. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the records show you
changed primary care physicians on August 1, 2021. The Plan states you were aware that you were not seen by
the Plan contract designated physician. The contract is clear that this is a copayment difference between your
primary care physician and any other type of specialist or physician. As members cannot have multiple primary
care physicians, the cost share was applicable.
The Plan is correct in this case. 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 specialist services other than
your Plan designated primary care physician. You changed physicians without working with the Plan to
facilitate the transfer. 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 $40 copayment for an office visit provided on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on November 17, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says prior authorization is required for an out-of-network visit. 
 
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 had network providers 
available who could have provided 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 Domiciliary services provided on November 17, 
2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency room visit and inpatient 
admission from September 14 to September 17. 
 
You asked the Plan to waive the copayments for the emergency room visit and hospital admission. You say that 
were at the hospital for one day, not three and did not have any therapy services rendered while there. The Plan 
denied your request. The Plan says you have been charged the correct copayment amounts. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay $90 copayment for an emergency room visit and $250 copayment per day 
for days 1-7 per admission. 
 
You have been asked to pay a $90 copayment for the emergency room visit. You have also been asked to pay a 
$750 copayment for the inpatient stay ($250/day x 3 days= $750). The total amount you owe is $840 ($90 + 
$750 = $840). The emergency room visit falls within the Emergency care benefit category and the inpatient 
hospital stay falls within the Inpatient hospital care benefit category.  This means that you have been asked to pay the correct amounts 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 emergency room visit and acute inpatient admission on 
September 14, 2021, to September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
August 25, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like reconsideration 
because the services rendered were necessary and not excessive. The Plan denied your request. The Plan says 
this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested comprehensive oral 
evaluation is covered once every three plan years. The record shows that the Plan processed and paid for a 
comprehensive oral evaluation which was provided on June 9, 2021. The frequency limitation for this service 
has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation (D0150) provided on August 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
November 8, 2021, to November 17, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that paying this kind of bill 
will be a hardship and you are low income. The Plan denied your request. The Plan says the copayment 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $295 copayment for each Medicare-covered hospital stay for days 1 to 6 and a $0 copayment for 
days 7 to 90.  The enrollee has been asked to pay a total of $1,770 ($295 copayment x 6 days = $1,770). An inpatient hospital 
stay falls within the Inpatient hospital care benefit category. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the inpatient hospital stay provided from November 8, 2021, to November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit provided on December 
27, 2021. 
 
You asked the Plan to waive the copayment for a telehealth visit. You say that the office visit you were charged 
for was just to schedule an appointment over the phone. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $10 for each covered telehealth visit.  
 
 The enrollee has been asked to pay $10 for the telehealth visit. Telehealth visits fall within the 
Physician/Practitioner services, including doctors office visits benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the telehealth visit provided on December 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on December 30, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that you burned your hand and foot, and this is 
emergency service. The Plan denied your request. The Plan says the medical group shows no approved referral 
for services rendered. 
 
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 had network providers 
available who could have provided 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 a specialist office visit provided on December 30, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis provided on March 30, 2021, 
and November 30, 2021. 
 
You asked the Plan to waive the copayment for an arthrocentesis. You say that it was an injection, not a 
surgery which is why you are questioning the cost for just an injection. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing 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 $350 
copayment for outpatient procedures and outpatient surgery.  
 
According to Medicare, an arthrocentesis is considered a surgical procedure. You have been asked to pay the 
allowed amount of $314.68, which is less than the $350 copayment for each arthrocentesis on March 30, 2021, and November 30, 2021. An arthrocentesis 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 arthrocentesis provided on March 30, 2021, and November 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for mental health telehealth services provided 
from October 26, 2020, to December 1, 2021. 
 
You asked the Plan to waive the copayments for the mental health telehealth services. You say that the provider 
informed you that there were no copayments for the services. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing 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 $40 
copayment for each therapy visit.  
 
The file shows that you had a total of 6 telehealth visits for mental health services from October 26, 2020, to December 1, 2021. Therefore, you have been asked to pay a $40 copayment for each of the mental health 
telehealth services, for a total of $240 ($40 copayment x 6 visits = $240). The mental health telehealth services 
fall within the Outpatient Mental Health 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 copayments 
for mental health telehealth services provided from October 26, 2020, to December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit received on June 
21, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you missed the 
appointment on June 21st so you shouldn't have to pay for it. The Plan denied your request. The Plan says the 
copayment was applied correctly. Medical records do show that you were seen on June 21, 2021, by the 
specialist.  
 
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 each in-person specialist visit.  You have been asked to pay $40 for the specialist office visit. Specialist office visits fall 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 the specialist office visit received on June 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an aminolevulinic acid topical solution 
provided on July 15, 2021. 
 
You asked the Plan to waive the coinsurance for the aminolevulinic acid topical solution. You say that the 
second part of the procedure was canceled and you do not feel you should be responsible for the initial 
coinsurance. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for each Part B drug.  
 
You have been asked to pay $76.42, which is less than 20% of the allowed amount for the aminolevulinic acid 
topical solution ($716.70 allowed amount x 20% coinsurance = $143.34). The aminolevulinic acid topical solution falls 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 an aminolevulinic acid topical solution provided on July 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a nerve destruction procedure performed on 
November 22, 2021. 
 
You asked the Plan to waive the deductible for the nerve destruction procedure. You say that you do not agree 
with the bill. The Plan denied your request. The Plan says the correct amount was applied to your deductible. 
 
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 $750 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Surgery and 
Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the nerve destruction procedure was performed on November 22, 2021. Therefore, we 
decided that the Plan does not have to waive the deductible for a nerve destruction procedure performed on 
November 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311). 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say 
that the requested items are a medical necessity for you. The Plan denied your request. The Plan says medical 
necessity rules for the requested items have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 an expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the requested items exceed your medical needs. 
You do not require a ventilator or non-proportional input devices (e.g., sip and puff, head array, etc.). You do 
not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an 
augmentative speech device or computer through the chair's drive control), or an attendant control. You have 3 
power options of tilt, recline, and power elevating leg rests but your strength and function support that you can 
control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller with harness and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the heavy-duty wheelchair, detachable arms (desk or 
full length) swing away detachable footrest (CPT code E1290). 
 
You asked the Plan to pre-approve the wheelchair. You say that you do not fit in a 22-inch wheelchair. You 
state that you are not able to walk because you had a stroke, you are weak on the left side of your body, and 
you are not even to get into your bed by yourself. The Plan denied your request. The Plan says they approved 
the correct code for heavy-duty wheelchair CPT code K0006 and have denied the incorrect code CPT code 
E1290 Heavy-duty wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The Plan approved the correct code for heavy-duty wheelchair CPT code K0006 and have denied the incorrect code CPT code E1290 Heavy-duty wheelchair because E1290 is not 
a valid code since 1993. Therefore, we decided that the Plan does not have to pre-approve the heavy-duty 
wheelchair, detachable arms (desk or full length) swing away detachable footrest (CPT code E1290).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Mental Health services provided on August 19, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient Mental Health services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says prior authorization is required for an 
out-of-network visit. 
 
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 had network providers 
available who could have provided 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 Outpatient Mental Health services provided on 
August 19, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99334) rendered by the out-of-network (OON) provider on August 24, 
2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99334) rendered by the out-of-network (OON) provider on August 24, 2021.