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

 
We decided that the Plan does not have to pay for surgical services (15777, 15200, 15201, 15860, 19537) 
provided February 10, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be billed as paid. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) codes 15777, 15200, & 15201. The Medicare Fee Schedule Database contains a 
surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is 
not medically necessary and will not be paid. Codes 15860 and 19537 were billed with 2 units of service and 
have a MUE of 1. The codes were not billed using the correct bilateral indicator. Based upon this information, 
we find that Medicare coverage criteria for the surgical services have not been met. Therefore, we decided that 
the Plan does not have to pay for surgical services (15777, 15200, 15201, 15860, 19537) provided February 10, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on May 
07, 2022. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you are on a fixed 
income and need assistance paying 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 $385 
copayment for ambulance services. 
 
You have been asked to pay a $385 copayment for ambulance transportation. This item/service 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 provided on May 07, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lidocaine pad 5%. 
 
You asked the Plan to pre-approve Lidocaine. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lidocaine pad 5%.  
 Benefits for Lidocaine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (G0402) provided March 10, 2022. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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, the CPT Code Manual definition of code G0402 is Initial preventive physical examination; face-to-
face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment. 
 
We find that CPT code G0402 is not supported in the medical record. Specifically, the record shows the visit 
took place more than 12 months from the enrollee's Medicare coverage effective date. Based on this 
information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we 
decided that the Plan does not have to pay for an office visit (G0402) provided March 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on April 
27, 2022, to May 11, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that this should be included in 
your total stay with the hospital. 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 $1,250 
copayment for Inpatient Hospital Care. 
 
You have been asked to pay a $1,250 copayment for inpatient hospital stay. This item/service 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 inpatient 
hospital stay provided on April 27, 2022, to May 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan of the chest provided on June 24, 
2022. 
 
You asked the Plan to waive the copayment for CT scan of the chest. You say that the copayment is too high 
and you cannot afford it. You also said that this scan is needed for your condition. 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 
copayment for diagnostic radiology services. 
 
You have been asked to pay a $250 copayment for CT scan of the chest. This item/service falls within the 
diagnostic radiology 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. You were charged $164.40 which is less than your contractual copayment amount of $250, 
therefore you are only responsible for $164.40. Therefore, we decided that the Plan does not have to waive the 
copayment for CT scan of the chest provided on June 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient care provided on October 04, 
2021, to October 14, 2021. 
 
You asked the Plan to reduce the copayment for the inpatient care. You say that your stay was longer due to an 
error by the doctor during a procedure. 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 $1,850 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,850 copayment for the inpatient care. This item/service 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. The file shows that you were in the hospital from October 4, 2021, to October 14, 2021. 
Per the EOC, there is a $370 copayment for days 1-5 of inpatient care. The total for your stay is $1,850 ($370 copayment x 5 days = $1,850). Therefore, we decided that the Plan does not have to reduce the copayment for 
the inpatient care provided on October 04, 2021, to October 14, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on June 
28, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that the ER did not do 
anything to help you, therefore you feel you should not have to pay the copayment. 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 an $85 
copayment for emergency care.  
 
You have been asked to pay an $85 copayment for an emergency room visit. An emergency room visit 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 an 
emergency room visit provided on June 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRI brain scan provided on May 09, 2022. 
 
You asked the Plan to waive the copayment for MRI brain scan. You say that you were told there were no 
charges for this procedure. 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 $105 
copayment for radiological diagnostic services, not including X-rays. 
 
You have been asked to pay a $105 copayment for MRI brain scan. This item/service falls within the 
radiological diagnostic services, not including X-rays 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 MRI brain scan provided on May 09, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tremfya. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tremfya.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the computed tomographic angiography 
(CTA) of the neck provided on May 24, 2022. 
 
You asked the Plan to reduce the copayment for the computed tomographic angiography (CTA) of the neck. 
You say that you feel the copayment is too high compared to what insurance paid. 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 $180 
copayment for advanced imaging services provided at a PCPs office, specialists office, or freestanding 
radiological facility. 
 
You have been asked to pay a $180 copayment for the computed tomographic angiography (CTA) of the neck. 
This item/service falls within the advanced imaging services provided at a PCPs office, specialists office, or 
freestanding radiological facility 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 
the computed tomographic angiography (CTA) of the neck provided on May 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opzelura. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Opzelura.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care on May 
03, 2022, to May 04, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says the cost sharing you are 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). Your contract with the Plan clearly says that you must pay a $20 
copayment per day, days 1-20 and a $188 copay per day, days 21-100 for a Medicare-covered stay. You are 
covered for up to 100 days per benefit period. A prior hospital stay is not required. We will only cover your 
stay if you meet certain Medicare guidelines, and your stay is medically necessary. There was a one day visit. 
Therefore, results the total cost sharing amount of $20.  
 
 You have been asked to pay a $20 copayment for skilled nursing facility (SNF) care. Skilled nursing facility 
(SNF) care falls within the Skilled nursing facility (SNF) 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 skilled nursing facility (SNF) care on May 03, 2022, to May 04, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on May 05, 2022. 
 
You asked the Plan to waive the deductible for an office visit. You say that you should not be responsible 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 
$158.30 deductible for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $158.30 deductible for an office visit. 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 deductible for an office visit provided on May 05, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ambulance services provided on 
February 21, 2022. 
 
You asked the Plan to reduce the copayment for the ambulance services. You say that the cost sharing amount 
is too 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 $345 
copayment for ambulance services. 
 
You have been asked to pay a $345 copayment for the ambulance services. This item/service 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 reduce the copayment for the ambulance 
services provided on February 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient care provided on May 10, 
2022, to May 14, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you cannot 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 $1,340 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,340 copayment for the inpatient care. This item/service 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. The file shows that you were in the hospital from May 10, 2022, to May 14, 2022. Per the 
EOC, you have a $335 copayment per day for days 1-6 of inpatient care. Since there is no copayment for the 
discharge date, the total for 4 days of inpatient care is $Therefore, we decided that the Plan does not have to 
waive the copayment for the inpatient care provided on May 10, 2022, to May 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays provided on June 13, 2022. 
 
You asked the Plan to waive the copayment for x-rays. You say that when you go to your normal clinic you 
usually dont have a copayment for x-rays. 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 Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for x-rays. 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 x-rays provided on June 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the Plan should consider your treatment history 
and previously approved claims. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the onabotulinumtoxina injections 
provided on March 25, 2022. 
 
You asked the Plan to waive the coinsurance for the onabotulinumtoxina injections. You say that you are 
requesting the services to be paid. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the onabotulinumtoxina injections. 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. The allowed amounts for the two doses are $24.68 and $6.17, and the 20% 
coinsurance comes to $4.94 and $1.23. The total for the injections is $6.17. Please note that the Plan confirmed 
with the provider that the provider will process reimbursement of $18.Therefore, we decided that the Plan does 
not have to waive the coinsurance for the onabotulinumtoxina injections provided on March 25, 2022.