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

 
We decided that the Plan does not have to pay for laboratory services provided on May 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 laboratory services provided on May 5, 2022, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a dermatological injection provided from 
May 12, 2022, to June 27, 2022. 
 
You asked the Plan to waive the coinsurance for a dermatological injection. You say that you should not have 
all these extra charges. 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% 
coinsurance for Medicare Part B prescription drugs ($63.60 x 5 visits = $318).  
 
You have been asked to pay a $318 total coinsurance for a dermatological injection. This item/service falls 
within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for a dermatological injection provided from May 12, 2022, to June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia provided on March 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for anesthesia. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 anesthesia provided on March 23, 2022, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound study of arm and leg arteries 
(93922) provided on February 16, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that these tests are required by 
Medicare and have always been paid in the past. 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 $125 
copayment for Medicare-covered radiological diagnostic services.  
 
You have been asked to pay a $67 copayment for an ultrasound. This service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. You have been asked to pay less than 
the contractually required copayment for this service. 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 ultrasound study of arm and leg arteries 
(93922) provided on February 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an outpatient hospital observation provided from 
July 18, 2022, to July 19, 2022. 
 
You asked the Plan to waive the cost for an outpatient hospital observation. You say that you were brought 
through the ER via ambulance but were made to wait in the waiting area for over 10 hours to get a room and 
see a provider. 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 $750 
deductible and a $125 copayment for outpatient hospital observation.  
 
You have been asked to pay a $750 deductible and a $125 copayment for an outpatient hospital observation 
($750 + $125 = $875). This item/service falls within the outpatient hospital observation benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the cost for an outpatient hospital observation 
provided from July 18, 2022, to July 19, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a minimally invasive lumbar decompression (MILD) 
procedure with an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a MILD procedure. 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 follows Medicare rules. Medicare rules say that effective for services performed on or after January 9, 
2014, PILD will be covered by Medicare through CED for beneficiaries with LSS who are enrolled in an 
approved clinical study that meets the following criteria. 
 
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 a MILD procedure. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the MILD procedure is 
experimental. More research is needed. 
 
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 MILD procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a minimally invasive lumbar decompression (MILD) procedure with an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99202) and an ultrasound of a pregnant uterus 
(76801) provided on May 13, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and uterine ultrasound. You say that you usually receive payment 
for these procedure codes and diagnoses. The Plan denied your request. The Plan says a prior authorization is 
required but was not obtained for the services rendered to the enrollee. 
 
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 
(99202) and an ultrasound of a pregnant uterus (76801) provided on May 13, 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 nursing facility care provided on April 14, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of our plans network) will not be 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 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 nursing facility care provided on April 14, 2022, 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on January 3, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
unaware that if you were not transported to the hospital, that you would have to pay for the service. The Plan 
denied your request. The Plan says the ambulance run sheet confirms that you declined emergency 
transportation. 
 
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 January 3, 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 the ambulance response and treatment with no 
transport (A0998) provided on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit with a test provided on 
May 18, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit with a test. You say that you should not need 
to pay a $40 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 $15 
copayment for Physician/Practitioner services, including doctors office visits and a $25 copayment for 
outpatient diagnostic tests ($15 + $25 = $40). 
 
You have been asked to pay a $40 total copayment for a specialist visit with a test. This item/service falls 
within the outpatient diagnostic tests and Physician/Practitioner services, including doctors office visits benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit with a test 
provided on May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 27, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 the laboratory services related to end-stage renal disease (ESRD) provided on June 27, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits provided on June 22, 2022. 
 
You asked the Plan to waive the copayment for office visits. You say that you did not go to the provider on the 
DOS. 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 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $50 copayment for office visits. 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 office visits provided on June 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a heart procedure provided on May 23, 
2022, to May 24, 2022. 
 
You asked the Plan to waive the copayment for a heart procedure. You say that the provider gave you a 
medication you are allergic to and you almost died. Therefore you feel you should not have to pay this. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for outpatient hospital services. 
 
You have been asked to pay a $325 copayment for a heart procedure. This item/service 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 a heart 
procedure provided on May 23, 2022, to May 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs HF system. 
 
You asked the Plan to pre-approve a CardioMEMs HF system. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 a CardioMEMs HF system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this 
time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
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 CardioMEMs HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMs HF system.
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) gastroenterologist. 
 
You asked the Plan to pre-approve an office visit. You say that your primary care physician (PCP) does not 
know anything about the Plan's approved provider but is familiar with the requested provider. You say you are 
undergoing testing and would like to see the requested provider. The Plan denied your request. The Plan says 
the requested provider is out-of-network, but the services can be safely provided in-network. 
 
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) 
gastroenterologist.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy services (97110, 
95992, 97113, 97530) provided on May 3, 2022 to June 21, 2022 
 
You asked the Plan to waive the copayment for the physical therapy services. You say that the services should 
be covered as you disagree with the charges. 
 The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment per visit for Outpatient rehabilitation services.  
 
 
  You have been asked to pay a $560 copayment per visit for 14 physical therapy visits. This item/service falls 
within the Outpatient rehabilitation 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 physical therapy services (97110, 95992, 97113, 97530) provided on May 3, 2022 to June 21, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a repeat blood draw provided on June 08, 
2022. 
 
You asked the Plan to reduce the copayment for a repeat blood draw. You say that you were called back to 
have your labwork redrawn due to an error. You feel you should not have to pay a copay for this second draw. 
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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for a repeat blood draw. 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. The labs that were done the second time were 
different than the labs from the first. Therefore, the decision is upheld. Therefore, we decided that the Plan does 
not have to reduce the copayment for a repeat blood draw provided on June 08, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 25, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 25, 2022.