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

 
We decided that the Plan does not have to waive the copayment for an office visit provided on November 07, 
2022. 
 
You asked the Plan to waive the copayment for an 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/primary care provider. 
 
You have been asked to pay a $10 copayment for an office visit. This item/service falls within the 
physician/practitioner services/primary care provider 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 office visit provided on November 07, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mammography provided on October 31, 2022. 
 
You asked the Plan to pay for mammography. You say that you are requesting reconsideration. 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). Therefore, we decided that the Plan does not have to pay for mammography provided 
on October 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the patient does not meet IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical management of hemorrhagic stroke. Their medical problems are stable and there are no 
complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network removal and 
replacement of an implanted spinal neurostimulator provided on August 19, 2022. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you cannot afford the cost 
share. 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 50% 
coinsurance for out-of-network outpatient surgery, including services provided in an ambulatory surgical 
center.  
 
You have been asked to pay a $3,381.73 coinsurance for an outpatient surgery ($6,763.47 allowed amount x 
50% = $3,381.73, rounded down). This item/service falls within the out-of-network outpatient surgery, 
including services provided in ambulatory surgical center benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an out-of-network removal and replacement of an implanted spinal 
neurostimulator provided on August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the enrollee would like to see the same 
provider as her husband. The Plan denied your request. The Plan says network providers are available to render 
necessary 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 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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a vacuum-assisted socket system and a vertical
shock-reducing pylon for the enrollee.
You asked the Plan to provide coverage for a vacuum-assisted socket system and a vertical shock-reducing
pylon. You say that this is medically necessary. The Plan denied your request.
The Plan says that the vacuum assisted socket system and vertical shock reducing pylon were requested but
does not meet Medicare criteria as reasonable and necessary.
Our Medical director looked at the case file and the reopen request. At issue is coverage for a vacuum-assisted
socket system and a vertical shock-reducing pylon. Our Medical Director states that the clinical documentation
by the provider does not sufficiently support that L5988, an endoskeletal pylon device that allows vertical
shock reduction between the foot and pelvis during ambulation, is medically reasonable and necessary for the
enrollee in this case. The evidence-based support is weak as does not indicate a vacuum-assisted socket system
significantly impacts function or prevents wound breakdown, based on an independent review of the literature.
The medical standards of practice are not met. Our physician reviewer found that the enrollee's condition does
not meet criteria for coverage of a vacuum-assisted socket system and a vertical shock-reducing pylon.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a vacuum-assisted socket system and a vertical shock-reducing pylon have not
been met. Therefore, we decided that the Plan does not have to provide coverage for a vacuum-assisted socket
system and a vertical shock-reducing pylon for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an injection provided on October 19, 2022. 
 
You asked the Plan to waive the cost share for an injection. You say that you disagree with the cost share. 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 $5,400 deductible which applies to Medicare Part B prescription 
drugs.  
 
The item or service you asked the Plan to waive the cost share for falls within the Medicare Part B prescription 
drugs benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$5,400 deductible which applies to Medicare Part B prescription drugs. You are being asked to pay $74.92 
towards your $5,400 deductible. This cost sharing is a contractual obligation that had not been met at the time 
an injection was received on October 19, 2022. Therefore, we decided that the Plan does not have to waive the 
cost share for an injection provided on October 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy procedure provided on 
October 6, 2022. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that you feel that the service was denied 
and should be 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 a $350 
copayment for outpatient surgery including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $190.03 copayment for an endoscopy because the allowed amount for this 
service is less than the $350 copayment. This item/service 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 an endoscopy procedure provided on October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care provided on March 14, 2022. 
 
You asked the Plan to pay for transitional care. You say that you are requesting reconsideration. 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). Therefore, we decided that the Plan does not have to pay for transitional care 
provided on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on October 07, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that this was medically necessary and should be 
covered. Submitted for geographical exception. 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). Therefore, we decided that the Plan does not have to pay for a nursing facility visit 
provided on October 07, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
November 1, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you were told a screening 
colonoscopy has a $0 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 in-network diagnostic colonoscopies provided at ambulatory surgical centers.  
 
The medical records show that a diagnostic colonoscopy was performed on November 1, 2022. You have been 
asked to pay a $275 copayment for the colonoscopy. This item/service falls within the outpatient surgery 
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 colonoscopy 
provided on November 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on August 26, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy services. You say that this was medically necessary and should 
be covered. We are in-network. The Plan denied your request. The Plan says There was no preauthorization by 
a primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and 
this was not an emergency. You are out-of-network with this plan. Therefore, the decision is upheld. 
 
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 physical therapy services provided on August 26, 
2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on October 10, 2022, to 
October 12, 2022. 
 
You asked the Plan to pay for home health services. You say that this was medically necessary and should be 
covered. You treated this patient in good faith. 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). Therefore, we decided that the Plan does not have to pay for home health services 
provided on October 10, 2022, to October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extra-oral posterior dental x-ray (D0251) provided on 
November 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your 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 an extra-
oral posterior dental x-ray (D0251) provided on November 3, 2022.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the copayment for the arthroplasty, acetabular and proximal femoral
prosthetic replacement (27130) provided from February 24, 2022, through February 25, 2022.
You asked the Plan to reduce the copayment for the arthroplasty. You say that your copayment should only be
$150. The Plan denied your request. The Plan says that this cost sharing was charged correctly. Maximus
overturned the Plan's denial. The Plan requesting a reopening based on the fact this was an outpatient service
and not an inpatient hospital stay.
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 enrollees must pay a $150 copayment for surgery services in an outpatient
hospital.
The Plan says you must pay $293.43 for the arthroplasty. Based on the Plan contract, however, you cannot be
asked to pay more than a $150 copayment for the arthroplasty. The Plan contract does not state that there is a
daily copayment for outpatient surgery services. This was only one service and therefore only the applicable
copayment is due. Therefore, we decided that the Plan has to reduce the copayment for the arthroplasty,
acetabular and proximal femoral prosthetic replacement (27130) provided from February 24, 2022, through
February 25, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on September 03, 2022, 
to September 24, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration. 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). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
care provided on September 03, 2022, to September 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for radiation therapy provided on February 1, 
2022, to February 28, 2022. 
 
You asked the Plan to waive the cost share for radiation therapy. You say that you disagree with the cost share. 
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 $450 
deductible and a $10 copayment per visit for outpatient diagnostic tests radiation therapy.  
 
You have been asked to pay a $450 deductible and a $10 copayment per visit for radiation therapy. The total 
allowed amount for the radiation therapy is $480. You are being asked to pay your $450 towards your 
deductible. You are being asked to pay $30 copayment for the radiation therapy ($10 x 3 visits = $30). 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 cost share for radiation therapy provided on February 1, 2022, to February 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
September 20, 2022, through September 26, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says payment cannot be issued as you have 
exceeded the lifetime maximum benefit for these services. 
 
The Plan must follow Medicare rules. The rules say that payment may not be made for more than 190 days of 
inpatient psychiatric hospital services during the patients lifetime.  
 
We looked at this file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the rules say that payment may not be made for 
more than 190 days of inpatient psychiatric hospital services during a patients lifetime. The record shows that 
you have exceeded the lifetime limitation of 190 days for inpatient psychiatric services provided. Therefore, we 
decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
September 20, 2022, through September 26, 2022.