Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye appointment provided on June 13, 
2022. 
 
You asked the Plan to waive the copayment for an eye appointment. You say that my EOC states I do not have 
a copayment for eye services, is this correct? The Plan denied your request. The Plan says you were charged 
this cost sharing 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 $30 
copayment for vision care.  
 
You have been asked to pay a $30 copayment for an eye appointment. An eye appointment 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 an eye appointment 
provided on June 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet-rich plasma injections. 
 
You asked the Plan to pre-approve these services. You say that this is the only resolution to avoid surgery. The 
Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that platelet-rich plasma injections are non-covered. 
 
We looked at the file and Medicare rules. The requested services are platelet-rich plasma injectinos. These 
services are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
platelet-rich plasma injections.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a diagnostic colonoscopy provided on May 17, 
2022. 
 
You asked the Plan to waive the cost for a diagnostic colonoscopy. You say that you've never had a copayment 
for a colonoscopy before, and you do not understand why you have one now. The Plan denied your request. 
The Plan says you were charged this cost sharing 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, and a $750 deductible for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $138.67 copayment, rather than the full copayment amount of $350 for a 
diagnostic colonoscopy. You have also been asked to pay a $536.09 of the deductible ($536.09 + $138.67 = 
$674.76). Your total charge will be $674.76. A diagnostic colonoscopy 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 cost for a diagnostic colonoscopy provided on May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
April 20, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. You say that the services were medically 
necessary. The Plan denied your request. The Plan says payment for code 87481 and 87653 is bundled into 
payment for code 87801. 
 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 codes 
87481 and 87653 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. 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 codes 87481 and 87653 billed for 
date of service April 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on April 
14, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not be 
responsible to pay this. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room visit. 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 an emergency room visit 
provided on April 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rybelsus. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rybelsus.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal and replacement of an implantable defibrillator 
(33264) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve replacement of an implantable defibrillator. You say that the requested 
service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage 
for OON services have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
removal and replacement of an implantable defibrillator (33264) to be provided by an OON provider.
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 May 
11, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not be 
responsible to pay this. 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 $15 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit provided on May 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a foot x-ray provided on May 03, 2022. 
 
You asked the Plan to waive the copayment for a foot x-ray. You say that you were dissatisfied with your care 
and want this copayment waived.. 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 $45 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $45 copayment for a foot x-ray. This item/service 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 a foot x-ray provided on May 03, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with a specialist to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the consultation with a specialist. You say that you need an evaluation and 
consultation. The Plan denied your request. The Plan says the Plan says the requested provider is an OON 
provider and there are multiple in-network providers that are available and equally qualified providers that the 
enrollee can receive the services that were requested. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a consultation with a specialist to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on 
July 25, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that this was your yearly 
mammogram and should not have 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 $59.82 
copayment for outpatient diagnostic tests and therapeutic services and supplies (x-rays and ultrasounds). 
 
You have been asked to pay a $59.82 copayment for the diagnostic mammogram. This item/service falls within 
the outpatient diagnostic tests and therapeutic services and supplies (x-rays and ultrasounds) 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 records show that the 
mammogram was ordered due to asymmetry found in the previous screening, making the procedure diagnostic 
in nature. The allowed amount for this procedure is $59.82. Since this amount is less than the $60 copayment per the EOC, youTherefore, we decided that the Plan does not have to waive the copayment for the diagnostic 
mammogram provided on July 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27590 billed for date of service August 5, 
2021. 
 
You asked the Plan to pay for procedure code 27590. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 27590 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 27590 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 27590 billed for date of service August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the podiatry visit provided on June 06, 
2022. 
 
You asked the Plan to reduce the copayment for the podiatry visit. You say that you thought you only needed to 
pay a $25 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 $40 
copayment for podiatry services. 
 
You have been asked to pay a $40 copayment for the podiatry visit. This item/service falls within the podiatry 
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 reduce the copayment for the podiatry visit 
provided on June 06, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance service provided on May 27, 
2022. 
 
You asked the Plan to waive the copayment for an ambulance service. You say that you were taken to the 
hospital against your will and should not have to pay 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 $275 
copayment for ambulance services. 
 
You have been asked to pay a $275 copayment for an ambulance service. This item/service 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 copayment for an ambulance 
service provided on May 27, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 4, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered by the Plan. 
The Plan denied your request. The Plan says the rendering and referring providers are both OON providers and 
there was no approved authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan 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 the laboratory services provided on May 4, 2022, 
by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on May 
27, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not be 
responsible to pay this. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room visit. 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 an emergency room visit 
provided on May 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services involving removal of pieces of 
toenail for detection of fungus or bacteria provided on May 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for pathology lab services. You say that the enrollee did not go directly to the lab 
and the participating doctor sent the specimen to process. Therefore, you say that the enrollee is not using out-
of-network benefits for these services. The Plan denied your request. The Plan says the services were rendered 
by an out-of-network provider. Furthermore, the Plan contacted the enrollee's primary care physician and 
determined that there was no referral on file. The Plan says that the enrollee does not meet the criteria for any 
exceptions which would allow the use of an out-of-network provider. 
 
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 surgical pathology services involving removal of 
pieces of toenail for detection of fungus or bacteria provided on May 18, 2022, by an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the Euflexxa injection provided on May 
02, 2022. 
 
You asked the Plan to reduce the coinsurance for the Euflexxa injection. You say that you feel the cost sharing 
is excessive. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the Euflexxa injection. This item/service 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. The allowed amount for the injection is $2,067.88. The 20% coinsurance is a 
total of $413.58. Since the actual charged amount of $413.42 is less, you are only responsible for the lesser 
amount. Therefore, we decided that the Plan does not have to reduce the coinsurance for the Euflexxa injection 
provided on May 02, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility stay provided on 
February 02, 2021, to February 24, 2021. 
 
You asked the Plan to waive the copayment for a skilled nursing facility stay. You say that you are finding it 
difficult to pay this. 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 $368 
copayment for skilled nursing facility (SNF) care. 
 
You have been asked to pay a $368 copayment for a skilled nursing facility stay. This item/service falls within 
the skilled nursing facility (SNF) 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 a 
skilled nursing facility stay provided on February 02, 2021, to February 24, 2021.