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

 
We decided that the Plan does not have to waive the copayment for the infusion therapy services provided by 
an in-network provider on September 7, 2022. 
 
You asked the Plan to waive the copayment for the infusion therapy services. You say that you do not 
understand the cost sharing. 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 $295 
copayment for in-network 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 a $187.39 copayment for the infusion therapy services because the allowed 
amount for these services is less than the $295 copayment. These items/services fall 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 infusion therapy services 
provided by an in-network provider on September 7, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
September 17, 2022. 
 
You asked the Plan to waive the copayment for physical therapy (PT) services. You say that you were informed 
there would only be a $275 copayment for the surgery. 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 $35 
copayment for outpatient rehabilitation service. 
 
You have been asked to pay a $35 copayment for physical therapy (PT) services. This item/service falls within 
the outpatient rehabilitation service 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 (PT) services provided on September 17, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the stress test performed on November 22, 2022. 
 
You asked the Plan to waive the copayment for the stress test. You say that you do not agree with paying for 
this service. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide records to show that this service was rendered. 
Therefore, we decided that the Plan has to waive the copayment for the stress test performed on November 22, 
2022.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (85025) provided on June 6, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough evidence to support the denial of 
payment for the laboratory services provided based on Medicare criteria. Therefore, we decided that the Plan 
has to pay for the laboratory services (85025) provided on June 6, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy provided on November 
10, 2022, to November 11, 2022. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that you disagree with the 
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 $60 
copayment for outpatient diagnostic tests/radiation therapy. 
 
You have been asked to pay a $60 copayment for radiation therapy. This item/service falls within the outpatient 
diagnostic tests/radiation therapy 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 
radiation therapy provided on November 10, 2022, to November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 07, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
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 $10 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $10 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a specialist office visit provided on November 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the pacemaker removal and replacement 
surgery provided on September 13, 2022. 
 
You asked the Plan to reduce the cost share for the pacemaker removal and replacement surgery. You say that 
you were told this was in-network 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 $1,000 deductible which applies to out-of-network outpatient surgery, 
including services provided at hospital outpatient facilities. Your contract with the Plan also says that there is 
40% coinsurance after the deductible has been met for out-of-network outpatient surgery, including services 
provided at hospital outpatient facilities.   
 
The remaining allowed amount after the deductible was satisfied is $10,646.42 ($11,646.42 original allowed 
amount - $1,000 deductible paid = $10,646.42 remaining allowed amount). The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the pacemaker removal and 
replacement surgery was received on September 13, 2022. 
 
You have also been asked to pay $4,258.57, which is 40% coinsurance of the allowed amount for the 
pacemaker surgery ($10,646.42 remaining allowed amount x 40% coinsurance = $4,258.57). You have been 
asked to pay a total of $5,258.57 ($1,000 deductible + $4,258.57 coinsurance = $5,258.57). This item/service 
falls within the outpatient surgery, including services provided at hospital outpatient facilities 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 reduce the cost share for the pacemaker removal and replacement surgery provided 
on September 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that this is the best chance at resuming normal activity. 
The Plan denied your request. The Plan says there is insufficient evidence of efficacy for this procedure. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wearable defibrillator provided on 
May 20, 2022. 
 
You asked the Plan to waive the coinsurance for the wearable defibrillator. You say that you felt the vest was 
unnecessary. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the wearable defibrillator. This item/service falls within the 
durable medical equipment 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. The total you owe is $616.19 ($3,080.95 allowed amount x 20% 
coinsurance = $616.19). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
wearable defibrillator provided on May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic eye exam provided on 
September 15, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic eye exam. You say that you thought the Plan 
offered a free eye exam 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 vision care. 
 
You have been asked to pay a $40 copayment for the diagnostic eye exam. This item/service falls within the 
vision 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 the diagnostic eye exam 
provided on September 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the diabetic test strips provided on 
December 05, 2022. 
 
You asked the Plan to waive the coinsurance for the diabetic test strips. You say that you were told this would 
be totally covered. 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 40% 
coinsurance for out-of-network diabetic supplies. 
 
You have been asked to pay 40% coinsurance for the diabetic test strips. This item/service falls within the out-
of-network diabetic 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 diabetic 
test strips provided on December 05, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the cost sharing for the wearable defibrillator provided on October 5, 
2022. 
 
You asked the Plan to waive the cost sharing for the wearable defibrillator. You say that you think that you 
were billed incorrectly. The Plan denied your request. The Plan says that this cost sharing was charged 
correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide any documentation to support when the wearable 
defibrillator was returned, or the second month of the rental. Therefore, we decided that the Plan has to waive 
the cost sharing for the wearable defibrillator provided on October 5, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on October 
03, 2022, to October 07, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
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 $1,180 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,180 copayment for inpatient hospital care. This item/service 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 care provided on October 03, 2022, to October 07, 2022.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Tecentriq. 
 
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 that the step therapy requirement is not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the enrollee has not tried and failed the Plan's required 
drug(s); however, there is no documentation of what drug(s) need to be trialed prior to approval of Tecentriq. 
MAXIMUS requested this information from the Plan but a response was not received. Without knowing the 
name(s) of the required drug(s), a determination based on step therapy requirements cannot be made. 
Therefore, we decided that the Plan has to pre-approve Tecentriq.  
 
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: Favorable

 
We decided that the Plan has to pay for a take-home supply of methadone (code G2078) provided on 
November 14, 2022. 
 
You asked the Plan to pay for a take-home supply of methadone. The Plan denied your request. The Plan says 
that an individual provider cannot bill for OTP services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason 
to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for a 
take-home supply of methadone (code G2078) provided on November 14, 2022.   
 
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 procedure code 99223 provided on March 19, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the medical records support the billing of 
code 99223 provided on March 19, 2022. The Plan denied your request. The Plan says the medical records do 
not support the billing of code 99223 provided on March 19, 2022. 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 procedure code 99223. Our reviewer says that the medical 
records do not support the billing of code 99223 provided on March 19, 2022. Our reviewer found the review 
indicates that the enrollee presented to the emergency department on March 19, 2022, with left arm weakness. 
He was evaluated and admitted with transient ischemic attack (TIA)/cerebrovascular accident (CVA). Current 
Procedural Terminology (CPT) code 99223 (1 unit) was not supported. This initial hospital care evaluation and 
management code requires a comprehensive history, a comprehensive examination and medical decision 
making of high complexity. In this case, the medical records submitted did not support a comprehensive 
history. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 provided on March 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (EKG) provided on December 01, 
2022. 
 
You asked the Plan to pay for an electrocardiogram (EKG). You say that this was medically necessary and 
should be covered. 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). This patient has many in-network options that are within 5 miles of her residence. 
Therefore, we decided that the Plan does not have to pay for an electrocardiogram (EKG) provided on 
December 01, 2022.