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

 
We decided that the Plan does not have to waive the copayment for emergency room services on May 29, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. 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 $120 
copayment for emergency room. Emergency care refers to services that are furnished by a provider qualified to 
furnish emergency services, and needed to evaluate or stabilize an emergency medical condition.  
 
You have been asked to pay a $120 copayment for emergency room services. 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 emergency room 
services on May 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a cataract removal provided on June 07, 
2022. 
 
You asked the Plan to waive the deductible for a cataract removal. You say that you cant afford 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 $250 
deductible for outpatient surgery including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $250 deductible for a cataract removal. 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 deductible for a cataract removal provided on 
June 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visits provided on April 
27, 2022, to May 12, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visits. You say that you feel all three visits 
should be considered one. 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 tier 1 specialist visits. 
 
You have been asked to pay a $90 copayment for the specialist office visits. This item/service falls within the 
tier 1 specialist 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. The file shows a total of three visits from April 27, 2022, to May 12, 2022. The $30 
copayment applies to each visit, for a total of $90. Therefore, we decided that the Plan does not have to waive 
the copayment for the specialist office visits provided on April 27, 2022, to May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a foam dressing, wound cover provided on March 30, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a foam dressing, wound cover. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 foam dressing, wound cover provided on March 
30, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nuclear medicine service provided on May 
23, 2022. 
 
You asked the Plan to waive the copayment for nuclear medicine service. You say that this was diagnostic and 
not therapeutic. 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 $60 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $60 copayment for nuclear medicine service. 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 nuclear medicine service provided on May 23, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on January 25, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 outpatient mental health services provided on 
January 25, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 2, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says services from 
non-participating providers are not covered unless they are authorized by the Plan before the services are 
provided. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on June 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an injection procedure for cholangiogram, 
a cholecystectomy, and inpatient hospital care provided from May 2, 2022, to May 27, 2022. 
 
You asked the Plan to waive the copayments for the injection, cholecystectomy, and inpatient care. You say 
that you overpaid for the services. 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 for outpatient surgery in an ambulatory surgical center or outpatient hospital facility. 
 
Your contract with the Plan also clearly says that you must pay $370 per day for days 1-5 and $0 per day for days 6-90 for inpatient care. 
 
You have been asked to pay a $350 copayment each for the injection and cholecystectomy. These 
items/services fall within the outpatient surgery in an ambulatory surgical center or outpatient hospital facility 
benefit category. You have also been asked to pay $370 per day for days 1-2 of inpatient care. This 
item/service falls within the inpatient hospital care benefit category. The total for all services is $1,440. 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 injection procedure for cholangiogram, a 
cholecystectomy, and inpatient hospital care provided from May 2, 2022, to May 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nasal endoscopy provided on April 12, 
2022. 
 
You asked the Plan to waive the copayment for the nasal endoscopy. You say that you should be charged $45 
for a specialists visit. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for outpatient hospital services.  
 
You have been asked to pay a $80.18 copayment for the nasal endoscopy which is less than the applicable 
copayment amount. The nasal endoscopy falls within the Outpatient Hospital Services benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the nasal endoscopy provided on April 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on December 18, 
2020, to December 28, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing the enrollee is being 
charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $285 copayment per day for days 17 of a hospital stay for all other members of our Northern 
California Region. Thereafter there is no charge for the remainder of your covered hospital stay. Also, you do 
not pay the copayment listed above for the day you are discharged unless you are admitted and discharged on 
the same day. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of 
inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a 
doctor's order. The day before you are discharged is your last inpatient day. $285 x 7 = $1,995. Therefore, 
results in the total cost sharing amount of $1,995.  The enrollee has been asked to pay a $285 copayment per day for inpatient hospital stay. Inpatient hospital stay 
falls within the Inpatient hospital care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital stay on December 18, 2020, to December 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an inpatient hospital stay provided on April 
10, 2022, to April 12, 2022. 
 
You asked the Plan to waive the deductible for an inpatient hospital stay. You say that the cost share applied is 
high. 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 
$302.79 deductible for medical benefits chart. 
 
You have been asked to pay a $302.79 deductible for an inpatient hospital stay. This item/service falls within 
the medical benefits chart 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 deductible for an inpatient 
hospital stay provided on April 10, 2022, to April 12, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transport services provided on August 9, 2021. 
 
You asked the Plan to pay for the ambulance transport services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan denied payment for ambulance transport services because 
the ambulance provider billed the services with modifier NN. The Plan states, per Medicare rules that 
origin/destination modifier NN is used for Skilled nursing facility (SNF) to SNF transport. A transport between 
two SNFs is not separately payable when a beneficiary is in a Part A covered SNF stay. However, the Plan 
provided a claim from the SNF that shows the enrollee received the ambulance transport during a Part B 
covered SNF stay. The Plan has provided no other rationale for their denial; therefore, our decision is based 
solely on what the Plan provided to us. We find that the Plan has not provided sufficient evidence to support 
their denial of payment for the ambulance transport services. Therefore, we decided that the Plan has to pay for 
the ambulance transport services provided on August 9, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an urgent care visit provided on May 15, 
2022. 
 
You asked the Plan to reduce the copayment for an urgent care visit. You say that you feel this should be 
reduced to a $25 copay rather than the $60. This is too costly. 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 $60 
copayment for urgently needed services. 
 
You have been asked to pay a $60 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 an urgent 
care visit provided on May 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 2, 2021 billed with 
codes 81406, 81201, 81162, and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says this panel for genetic testing was not coded correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 2, 2021 billed with codes 81406, 81201, 81162, and 81408.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a dermatology appointment provided on 
April 21, 2022. 
 
You asked the Plan to waive the copayment for a dermatology appointment. You say that the provider didnt 
help you at all, only spoke with you for a few minutes, then left. 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 $20 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $20 copayment for a dermatology appointment. 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 dermatology appointment provided on April 21, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an office visit provided on May 14, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that your oropharynx was bruised 
during a previous procedure which led to the emergency room visits. The Plan denied your request. The Plan 
says that the copayment applied is correct. 
 
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 $90 copayment for each emergency room visit.  
 
The Plan says you must pay a $10 copayment for an office visit. Based on the Plan contract, however, you 
cannot be asked to pay a $10 copayment for an office visit when you have already been asked to pay a $90 
copayment for an emergency room visit. Therefore, we decided that the Plan has to waive the copayment for an 
office visit provided on May 14, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter. 
 
 
Your complaint about the quality of treatment during a previous procedure performed on a different date of 
service 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services 
provided to the enrollee from March 26, 2022, to April 4, 2022. 
 
You asked the Plan to pre-approve the services. You say that you are authorized to pursue Medicare claims for 
services provided to dually eligible Medicare and Medicaid beneficiaries, and for which the state Medicaid 
program has paid. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee had received 100 days of SNF care during the benefit period from October 19, 
2021, to March 25, 2022. The Plan has covered 100 days of SNF care. 
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we 
decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services provided to 
the enrollee from March 26, 2022, to April 4, 2022.