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

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on April 6, 
2022. 
 
You asked the Plan to pay for the services. You say that you declined to be transported to the hospital. The Plan 
denied your request. The Plan says there was treatment with no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 6, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided to the enrollee on 
April 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection procedure for contrast knee arthrography 
provided on November 16, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an injection procedure for contrast knee arthrography. You say that you would 
like to request reconsideration of the denied claim. The Plan denied your request. The Plan says The services 
are not authorized because the provider is a non-network provider who does not work with the 
members health plan, and the member self-directed for care. 
 
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 an injection procedure for contrast knee 
arthrography provided on November 16, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy with lesion removal 
performed on March 22, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that this was a routine colonoscopy 
and should be covered. 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 no 
coinsurance, copayment, or deductible for a colorectal cancer screening. If a polyp or other tissue is found and 
removed, you may have to pay copayments for physician services and outpatient surgery. Your contract with the Plan also clearly says that you must pay a $300 copayment for each outpatient hospital 
visit. 
 
The record shows that lesions were removed during the procedure. Therefore, you have been asked to pay a 
$300 copayment for the colonoscopy. The colonoscopy 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 a colonoscopy with lesion removal performed on March 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 30, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says unauthorized, non-plan 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 requested provider in this case is not a network provider with the Plan. 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 medical services provided on March 30, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 11, 2020. 
 
You asked the Plan to pay for the lab services. You say that your lab does not have a contract in place with the 
dialysis facility. The Plan denied your request. The Plan says these lab services are included in the payment to 
the dialysis facility. The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services 
are not separately payable. Labs should bill the facility directly for lab services as they are considered part of 
the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does 
not have to pay for lab services provided on September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for eye glasses (V2784, V2750, V2020) provided March 7, 
2022. 
 
You asked the Plan to pay for the eye glasses. You say that the eye glasses should be fully covered. The Plan 
denied your request. The Plan says the allowable amount has been paid towards the eyeglasses. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan provides a $150 annual allowance towards covered vision hardware. 
 
We looked at the file and the Plan's rules. The plan paid the allowed $150 towards the eyewear. The total cost 
of the glasses was $258.98. The amount in excess of the $150 allowance is the enrollee's responsibility. Based 
on this information, we decided that the Plan's rules for coverage of the eye glasses have not been met. 
Therefore, we decided that the Plan does not have to pay for eye glasses (V2784, V2750, V2020) provided 
March 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an endoscopy procedure and blood oxygen 
monitoring performed on December 27, 2021. 
 
You asked the Plan to waive the copayments for the endoscopy and blood oxygen monitoring. You say that the 
tests were ordered by your doctor and should be covered. 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 $395 
copayment for surgery or other services provided at an outpatient hospital. 
 
Your contract with the Plan also clearly says that you must pay a $30 copayment for non-radiological 
diagnostic services. You have been asked to pay a $395 copayment for the endoscopy. The endoscopy falls within the Outpatient 
Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. You have also been asked to pay a $30 copayment for the blood oxygen monitoring. 
The blood oxygen monitoring falls within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. The total for the visit is $425. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments 
for an endoscopy procedure and blood oxygen monitoring performed on December 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 26, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you filed this claim timely so it should be 
paid. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.  The Plan has 
requested information from your multiple times regarding who referring the patient for these services and you 
have not responded. 
 
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 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 medical services provided on February 26, 2021, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided on March 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing services. You say that you disagree with this denial because you 
were not aware of the requirement for authorization. The Plan denied your request. The Plan says unauthorized, 
non-plan 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. 
 
Neither your organization nor the referring provider in this case is a network provider with the Plan. 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 drug testing services 
provided on March 7, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with procedure codes 82310, 82728, 
83540, 83550, 83970, and 84100 for date of service January 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that this claim should be reprocessed because these 
tests are pertinent for the patient. The Plan denied your request. The Plan says these services are bundled into 
the dialysis facility payment. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services billed with procedure codes 82310, 82728, 83540, 83550, 83970, and 84100 for date of service 
January 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the thoracic 
spine and MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the thoracic spine and an MRI of the lumbar spine. You say that 
the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI of the thoracic spine and an 
MRI of the lumbar spine. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the reason for the requested spinal MRI studies is not specified in the records. There is no 
detailed neurological exam included. No red flags are identified. No plain film studies have been done. Medical 
necessity of the requested studies has not been provided in the records. 
 
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 MRI of the thoracic spine and an MRI of the lumbar spine have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of 
the thoracic spine and MRI of the lumbar spine.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on January 
24, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you do not feel you 
should be responsible for any costs as a result of the enrollee's hospitalization. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $270 copayment for ambulance services.  
 
The enrollee has been asked to pay a $270 copayment for the ambulance services. This copayment applies 
regardless of the reason for the services. Please note that because the allowed amount for this ambulance 
service ($235) is less than the copayment responsibility, the enrollee is responsible for the full allowed amount. 
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 ambulance services provided on January 24, 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient skilled nursing facility (SNF) 
care provided from January 1, 2022, through January 17, 2022. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $0 
copayment per day, for days 1-20 and a $178 copayment per day, for days 21-100 for skilled nursing facility 
care.  
 
 
 
 You have been asked to pay $2,848 ($178 copayment x 16 days) for the skilled nursing facility care provided. 
You previously received skilled nursing facility care from December 12, 2021, through December 31, 2021. 
These services were provided in the same benefit period and were not assessed a copayment. The Plan contract 
says that you must pay a $0 copayment for days 1-20 and a $178 copayment for days 21-100 for skilled nursing 
facility care. 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 the inpatient skilled nursing facility (SNF) 
care provided from January 1, 2022, through January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for debridement, subcutaneous tissue on 
October 28, 2021. 
 
You asked the Plan to waive the copayment for debridement, subcutaneous tissue. You say that you would like 
to appeal the cost share. The Plan denied your request. The Plan says the copayment applied 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 $200 
copayment for debridement, subcutaneous tissue.  
 
You have been asked to pay a $200 copayment for debridement, subcutaneous tissue. Debridement, 
subcutaneous tissue 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 debridement, subcutaneous tissue on October 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy on February 28, 2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the copayment applied 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 $300 
copayment for a colonoscopy.  
 
You have been asked to pay a $300 copayment for a colonoscopy. A colonoscopy 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 a colonoscopy on February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on October 15, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the assisted living facility should have 
obtained prior authorization. The Plan denied your request. The Plan says unauthorized, non-plan 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 in this case is not a network provider with the Plan. 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 medical services provided on October 15, 2021, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 30, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you do not know why you were being billed for lab 
work. The Plan denied your request. The Plan says the services have been provided out-of-network and were 
not approved in advance. 
 
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 office visit provided on June 30, 2021, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87481, 87640, 87641, 87653) provided 
August 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed codes are not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Codes 87150, 87481, 87640, 87641, & 87653 
shared bundled relationships with codes 87500 & 87801 which were already approved. 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 lab services (87150, 87481, 
87640, 87641, 87653) provided August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on November 2, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you have provided documentation to support 
the code billed. The Plan denied your request. The Plan says unauthorized, non-plan 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 requested provider in this case is not a network provider with the Plan. 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 medical services provided on November 2, 2021 
by an out-of-network (OON) provider.