Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an outpatient hospital observation provided from 
February 28, 2022, to March 1, 2022. 
 
You asked the Plan to waive the cost for an outpatient hospital observation and diagnostic radiology. You say 
that you were not provided with adequate care and therefore should have this cost waived. The Plan denied 
your request. The Plan says the cost (deductible and 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 a $750 deductible for applicable services, and a $125 copayment for outpatient hospital observation. 
 
The enrollee has been asked to pay a deductible amount of $672.90 and the $125 copayment for an outpatient 
hospital observation, totaling $797.90 ($672.90 + $125 = $797.90). An outpatient hospital observation falls 
within the Outpatient Hospital Observation 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 cost for an outpatient hospital observation provided from 
February 28, 2022, to March 1, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for colostomy supplies on March 11, 2022. 
 
You asked the Plan to waive the coinsurance for colostomy supplies. 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 prosthetic devices and medical supplies. Devices (other than dental) that replace all or part of a 
body part or function. These include but are not limited to: colostomy bags and supplies directly related to 
colostomy care, pacemakers, braces, prosthetic shoes, artificial limbs, and breast prostheses (including a 
surgical brassiere after a mastectomy). Includes certain supplies related to prosthetic devices, and repair and/or 
replacement of prosthetic devices. Also includes some coverage following cataract removal or cataract surgery 
 see Vision Care later in this section for more detail. The allowed amount is $939.63. $939.63 x 20% = 
$187.92. Therefore, results in the total cost sharing amount of $187.92. 
 
 You have been asked to pay a 20% coinsurance for colostomy supplies. Colostomy supplies fall within the 
Prosthetic devices and related supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for colostomy supplies on March 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional one-way routine transportation trips. 
 
You asked the Plan to pre-approve 10 additional one-way routine transportation trips. You say that these trips 
are necessary. The Plan denied your request. The Plan says there is no additional benefit for routine 
transportation after the services have been exhausted. 
 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 a maximum of 40 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 10 additional one-way routine transportation trips.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for office visit on May 21, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that this should have been waived because 
it was a COVID-19 visit. You did not go to the doctors office for any other reason. You feel that the plan 
should pick it up and is unsure what the other tests were supposed to be beside COVID-19. The Plan denied 
your request. The Plan says that the cost sharing you are being charged is correct. 
 
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. Without the correct Evidence of Coverage (EOC), there is no way of knowing 
whether the copayment being charged is correct. Therefore, we decided that the Plan has to waive the 
copayment for office visit on May 21, 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: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Panel testing provided January 31, 2022. 
 
You asked the Plan to pay for the Tempus xT Panel testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test is not FDA-approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xT tesing is not FDA approved. 
Based on this information, we decided that Medicare rules for coverage of the Tempus xT Panel testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xT Panel testing 
provided January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of tooth #14 (D7210) provided on April 19, 
2022. 
 
You asked the Plan to pay for an extraction. You say that you do not understand why this claim was denied. 
The Plan denied your request. The Plan says extractions (D7210) are not covered by your supplemental dental 
benefits. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extraction of tooth #14 (D7210) provided on April 19, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90834) provided 
April 28, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you request reconsideration for this 
claim and request CPT code be reprocessed and paid. The Plan denied your request. The Plan says there is not 
documented contact with the attending/primary care physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy 
services (90834) provided April 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided 
from April 14, 2022, to April 18, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. 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 $50 
copayment for each emergency room visit.  
 
You have been asked to pay a $50 copayment for the ER visit. The ER visit 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 an emergency room (ER) visit 
provided from April 14, 2022, to April 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty (27447). 
 
You asked the Plan to pre-approve the total knee arthroplasty. You say that the surgical procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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 the total knee arthroplasty. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found documentation is not evident regarding trial and failure of recent, reasonable, 
and comprehensive less invasive conservative care measures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the total knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a total knee arthroplasty (27447).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services on February 03, 2022. 
 
You asked the Plan to waive the copayment for outpatient services. 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 $40 
copayment per visit for specialist may apply for Medicare-covered physician services. We cover medically-
necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or 
injury. Covered services include but are not limited to services in an emergency department or outpatient clinic, 
such as observation services or outpatient surgery. 
 
 
 
 You have been asked to pay a $40 copayment for outpatient services. Outpatient services fall within the 
Outpatient hospital 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 outpatient 
services on February 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #22 and 27 (D2950) provided on April 
11, 2022. 
 
You asked the Plan to pay for core build up. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says core build up (D2950) is not covered by your supplemental dental 
benefits. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core build 
up on tooth #22 and 27 (D2950) provided on April 11, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a radiofrequency ablation vein treatement (36475). 
 
You asked the Plan to pre-approve the vein treatment. You say that this service is medically necessary. The 
Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for laser or radiofrequency ablation treatment, the 
patient's anatomy and clinical condition must be amenable to the proposed treatment. 
 
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 the vein treatment. Our reviewer says 
that the requested treatment is medically necessary. Our physician reviewer found documentation supports the 
medical necessity of the treatment in question. There is satisfactory documentation of a venous stasis ulcer in 
the territory of the vein to be treated. There is also satisfactory documentation of adequate arterial perfusion to 
the lower extremity. There is documentation of a patent deep venous system and significant reflux in the vein 
to be treated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the vein treatment have been met. Therefore, we decided that the Plan has to 
pre-approve a radiofrequency ablation vein treatement (36475).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921 x 4), and extractions of tooth #30 
and 31 (D7210) provided on March 3, 2022. 
 
You asked the Plan to pay for irrigation and extractions. You say that you were never told these procedures 
were not covered. The Plan denied your request. The Plan says gingival irrigation (D4921) is not covered by 
your dental benefits. The Plan also says that your benefit for extractions (D7210) has been exhausted. 
 
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, gingival irrigation is not among those 
covered under this benefit. The record shows your benefit for extractions has been exhausted on date of service 
March 3, 2022. Therefore, we decided that the Plan does not have to pay for gingival irrigation (D4921 x 4), 
and extractions of tooth #30 and 31 (D7210) provided on March 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance on March 11, 2022, to March 
31, 2022. 
 
You asked the Plan to waive the copayments for ambulance. You say that you are low income and cant afford 
all the ambulance bills that are coming in. 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 $125 
copayment per one-way trip for Medicare-covered ambulance services. Covered ambulance services include 
fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide 
care if they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan. There were 6 trips. $125 x 6 = $750. Therefore, 
results in the total cost sharing amount of $750. 
 You have been asked to pay a $125 copayment per one way for ambulance. Ambulance falls within the 
Ambulance 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 ambulance on 
March 11, 2022, to March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hepatitis C antibody measurement 
provided on April 7, 2022. 
 
You asked the Plan to waive the copayment for the laboratory testing. You say that you went in for a routine 
physical with your physician. 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 $10 
copayment per day for laboratory services. This test is considered a separate diagnostic service not part of your 
annual physical. 
 
You have been asked to pay a $10 copayment for the laboratory testing. The laboratory test 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 the hepatitis C antibody measurement provided on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) provided by a 
participating provider on March 23, 2022. 
 
You asked the Plan to pay for panoramic radiographic imaging. You say that you were never advised that there 
would be a charge for the x-rays. The Plan denied your request. The Plan says the rendered dental work is not a 
covered benefit. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
panoramic radiographic imaging (D0330) provided by a participating provider on March 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for infliximab injections provided from 
February 3, 2022, to March 31, 2022. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you should be reimbursed for the 
services. 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 chemotherapy drugs. 
 
Drug Allowed Amount 20% Coinsurance 
Infliximab  February 3, 2022 $1,515.20 $303.04 
Infliximab  March 31, 2022 $1,515.20 $303.04 
Total:  $606.08 
 
 You have been asked to pay a total of $606.08, which is 20% of the allowed amount for the injections. The 
injections fall within the Medicare Part B Prescription Drugs benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for infliximab injections provided from February 3, 2022, to March 31, 2022.