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

 
We decided that the Plan does not have to pay for a 3rd injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; third and any additional level provided on October 28, 2021. 
 
You asked the Plan to pay for a 3rd injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or 
sacral; third and any additional level. The Plan denied your request. The Plan says the facet joint injection is 
not medically necessary and does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 pay for a 3rd injection(s), diagnostic or therapeutic 
agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance 
(fluoroscopy or CT), lumbar or sacral; third and any additional level. Our reviewer says that a 3rd injection(s), 
diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with 
image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level is not medically 
necessary. Our physician reviewer found there is no documentation of a special need for 3 levels to be 
performed. The third level exceeds utilization criteria and was not medically reasonable or necessary. 
 
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 3rd injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or 
sacral; third and any additional level have not been met. Therefore, we decided that the Plan does not have to 
pay for a 3rd injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves 
innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional 
level provided on October 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy with 
biopsy provided on May 24, 2021. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy. You say that you feel that 
you should not pay the copayment as this service should be covered at 100%. The Plan denied your request. 
The Plan says you were 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 $200 
copayment per visit for Medicare-covered outpatient surgery or procedure at an ambulatory surgical center 
(ASC).  
 
You have been asked to pay a $200 copayment for an esophagogastroduodenoscopy. An 
esophagogastroduodenoscopy 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 esophagogastroduodenoscopy with biopsy provided on May 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9338) provided on August 6, 2021. 
 
You asked the Plan to pay for the home infusion therapy (S9338). You say that the patient was serviced in good 
faith and other claims for the same service were paid. You say that claim should be approved and paid at 100%. 
The Plan denied your request. The Plan says the billed code is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
  We find that CPT code S9338 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy (S9338) have not been met. Therefore, we decided that the Plan does 
not have to pay for home infusion therapy (S9338) provided on August 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an inpatient hospital stay provided from 
December 29, 2021, to January 6, 2022. 
 
You asked the Plan to reduce the copayment for an inpatient hospital stay. You say that your total copayment 
for the inpatient stay should be $920. 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 $285 
copayment per day for days 1-6 for an inpatient hospital stay. The contract also says there is a $0 copayment 
for days 7-90.  
 The record shows the claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $1,710, which is a $285 copayment per day for days 1-6 for an inpatient hospital stay from December 
29, 2021, to January 6, 2022 ($285 copayment x 6 days = $1,710). There is no charge for days 7-90. An 
inpatient hospital stay falls within the Inpatient Hospital Care benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the copayment for an inpatient hospital stay provided from December 29, 2021, to January 6, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve homecare services-personal care. 
 
You asked the Plan to pre-approve homecare services-personal care. You say that you can hardly walk, and 
your hip has been bothering you lately. You say you need extra help around the house. The Plan denied your 
request. The Plan says custodial care is excluded from coverage. 
 
The Plan contract says homemaker services include basic household assistance, including light housekeeping 
or light meal preparation are not covered under any condition. 
 
We looked at the file and the Plans rules. The file shows that homemaker services include basic household 
assistance, including light housekeeping or light meal preparation are not covered under any condition. 
Therefore, we decided that the Plan does not have to pre-approve homecare services-personal care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on September 30, 2021. 
 
You asked the Plan to waive the copayment for An office visit. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the copayment applied was 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 $5 
copayment for an office visit.  
 
You have been asked to pay a $5 copayment for an office visit. An office visit 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 an office visit on September 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transthoracic echocardiogram (TTE) with 
doppler provided on June 30, 2021. 
 
You asked the Plan to waive the copayment for the TTE with doppler. You say that you do not remember 
seeing a cardiologist on that day. 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 $100 
copayment for diagnostic procedures and tests, including ultrasounds.  
 
The file shows that you were only charged the specialist visit copayment of $40, which is less than the $100 
copayment for the TTE with doppler. The TTE with doppler 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 
transthoracic echocardiogram (TTE) with doppler provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telephone evaluation and management service (99442) 
provided on November 22, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for telephone evaluation and management service. You say that this provider is 
credentialed per the Plan's guidelines, and you want this claim processed without the authorization since this is 
a network provider. The Plan denied your request. The Plan says this provider is not a network provider with 
the Plan, and they have also determined that these services are not urgent or emergent, nor were they approved 
in advance. The Plan also says a referral was not authorized by the primary care 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 telephone evaluation and management service 
(99442) provided on November 22, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from June 
19, 2020, through July 23, 2020, billed with code GAKE1. 
 
You asked the Plan to pay for the SNF services as billed. You say that the records support that billed HIPPS 
code. The Plan denied your request. The Plan says there is not sufficient information in the records provided 
that support the functional ability coding of Section GG. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for SNF services is based on a HIPPS 
code with five case-mix groups which are assigned based on the information from the MDS assessment. The 
rules say that for reporting functional abilities in Section GG, facilities must assess self-care performance based 
on direct observation, incorporating resident self-reports and reports from qualified clinicians, care staff, or 
family documented in the residents medical record during the three-day assessment period. It is expected that 
an interdisciplinary team of qualified clinicians is involved in assessing the resident during the three-day 
assessment period. 
 
We looked at the file and Medicare rules. In this case, there is a lack of documentation from the three-day 
assessment period to support the coding of Section GG. We find that there were 2-3 daily nursing assessments 
which did provide some documentation regarding the enrollees functional abilities, but these did not include 
detailed information regarding how the abilities were assessed. This is the only signed, primary source 
documentation of functional abilities within the three-day assessment period. Assessments from physical and 
occupational therapy were not done until beyond this three-day period and cannot be used to support this 
coding. There is no evidence of an interdisciplinary evaluation of functional abilities during the required time 
period. Based on this information, we decided that Medicare rules for coverage of the SNF services as billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility 
(SNF) care provided from June 19, 2020, through July 23, 2020, billed with code GAKE1.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an external electrocardiography (ECG) 
provided on July 1, 2021. 
 
You asked the Plan to waive the copayment for an external ECG. You say that an insurance representative 
wrongly signed your father up for managed Medicare for 2021. 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). The enrollees contract with the Plan clearly says that you must pay 
a $40 copayment for in-network outpatient diagnostic testing, including ECGs at a specialist office.  
 
 The record shows this claim was approved, and cost sharing applies. The enrollee has been asked to pay a $40 
copayment for an external ECG. An external ECG 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 an external 
electrocardiography (ECG) provided on July 1, 2021.  
 
Your complaint about the insurance representative wrongly signing your father up for this Plan is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
November 11, 2021, to November 23, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you are on a fixed 
income and cannot afford the copayment. 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 $100 
copayment per day for days 1-5 for an inpatient hospital stay. The contract also says that there is a $0 
copayment per day for days 6-90.  
 You have been asked to pay a total of $500, which is a $100 copayment per day for days 1-5 of an inpatient 
hospital stay ($100 copayment x 5 days = $500). There is no charge for days 6-90. An inpatient hospital stay 
falls within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an inpatient hospital stay provided from November 11, 2021, to November 23, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 8, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the claim reprocessed for payment. 
The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and there 
was no referral from an in-network provider or an approved authorization. Also, the service rendered was not 
urgent or emergent. 
 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 office visit provided on December 8, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on December 16, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth visit. You say that the provider is enrolled, and an in-network 
provider. Therefore, the services rendered should be paid. The Plan denied your request. The Plan says the 
rendering provider is an out-of-network provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 a telehealth visit provided on December 16, 2021, 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Ambulance Transportation on April 12, 
2018. 
 
You asked the Plan to waive the copayment for Ambulance Transportation. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says the copayment applied was 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 Ambulance Transportation.  
 
You have been asked to pay a $300 copayment for Ambulance Transportation. Ambulance Transportation 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 
Ambulance Transportation on April 12, 2018.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the intravitreal injection provided on 
September 10, 2021. 
 
You asked the Plan to waive the copayment for the intravitreal injection. You say that you've had many 
injections in the eye from the same provider and they've always been covered. 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 $20 
copayment for each Medicare-covered outpatient physician service provided by an ophthalmologist or 
optometrist. You pay these amounts until you reach the out-of-pocket maximum.   
 
You have been asked to pay a $20 copayment for the intravitreal injection. The intravitreal injection falls 
within the Vision care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
intravitreal injection provided on September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam provided on November 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that a routine eye exam does not need a primary care 
physician referral. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 eye exam provided on November 1, 2021, by 
an out-of-network (OON) provider.