Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on November 17, 
2021, to November 21, 2021. 
 
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 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 $250 
copayment for per day, days 1 to 5 and $0 copayment per day, days 6 to 90 for inpatient hospital stay inpatient 
hospital care. 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. There were 4 days, resulting in the 
amount of $1000. Therefore, result in the total cost-sharing amount of $1000.  
 
 
 You have been asked to pay a $250 copayment for each inpatient hospital stay. 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 
inpatient hospital stay on November 17, 2021, to November 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a 
LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care hospital services that can safely be provided at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary at this 
time as it would not be clinically advantageous. Completion of the treatment at the current facility is 
recommended.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the scanning computerized ophthalmic 
diagnostic imaging (92133) provided on March 9, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic imaging. You say that this was an annual 
glaucoma screening visit, and you should not be responsible for a copay. The Plan denied your request. The 
Plan says the copayment amount you are being charged is correct. The Plan also says that you were seen for an 
evaluation of possible stye and an evaluation of dermatochalasis of eyelid for diabetes mellitus, the provider 
did not bill for a glaucoma screening. 
 
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 
copay for Vision services covered by Medicare.  
 
 
 You have been asked to pay a $5 copay for the diagnostic imaging. The diagnostic imaging 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 scanning computerized 
ophthalmic diagnostic imaging (92133) provided on March 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for colonoscopy on January 18, 2022. 
 
You asked the Plan to waive the cost-sharing for colonoscopy. You say that there is no way you can afford this 
because you are on a fixed income. 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 $350 
copayment for diagnostic colonoscopy at an ambulatory surgical center. Covered services include, but are not 
limited to: other outpatient diagnostic tests. $550 + $350 = $900. Therefore, result in the total cost-sharing 
amount of $900.  You have been asked to pay a $550 deductible and a $350 copayment for colonoscopy. Colonoscopy 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 cost-sharing for colonoscopy on January 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the non-emergency ambulance services 
provided on April 21, 2022. 
 
You asked the Plan to reduce the copayment for the ambulance services. You say that the amount of the bill is 
extremely high and will create financial hardship. 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 $280 
copayment per date of service for non-emergency ambulances.  
 
You have been asked to pay a $280 copayment for non-emergency ambulance services. Ambulance services 
fall 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 non-emergency ambulance services provided on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on March 14, 2022. 
 
You asked the Plan to pay for the bone replacement graft. You say that you received the bone replacement graft 
because you have gum bone loss due to your periodontal disease. You also say that You are on a fixed income. 
The Plan denied your request. The Plan says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft for ridge preservation (D7953) provided on March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal system, below knee addition identified 
with code L5910. 
 
You asked the Plan to pre-approve an endoskeletal system, below knee addition. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a physician 
order. 
 
The record does not contain a valid physician order for the requested item in this case. Review of the file shows 
that the physician office visit notes do not corroborate the vendor's notes showing the need to replace this 
specific item. The notes do not show why the enrollee's current L5910, alignable System cannot be used for 
approved replacement socket. Therefore, we decided that the Plan does not have to pre-approve an endoskeletal 
system, below knee addition identified with code L5910.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), breast, without and 
with contrast material(s), including computer-aided detection (computer-aided detection (CAD) real-time 
lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral (77049). 
 
You asked the Plan to pre-approve a breast MRI. You say that an MRI is necessary as a preventative procedure. 
The Plan denied your request. The Plan says medical necessity of a breast MRI has not been established. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 breast MRI. Our reviewer says that a 
breast MRI is not medically reasonable and necessary. Our physician reviewer found the American College 
radiology recommends screening MRI for those with a lifetime risk >20%. You do not have breast cancer and 
are not at high risk. The request for breast MRI is not reasonable and 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 breast MRI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI), breast, without and with contrast material(s), 
including computer-aided detection (computer-aided detection (CAD) real-time lesion detection, 
characterization and pharmacokinetic analysis), when performed; bilateral (77049).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a CPAP device provided from April 11, 
2021, to November 11, 2021. 
 
You asked the Plan to waive the coinsurance for a CPAP device. You say that you should not have this 
coinsurance. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for durable medical equipment (DME). The allowed amount of this item is $39.75 resulting in a 
coinsurance amount of $7.95 (8 months x $7.95 = $63.60).  
 
You have been asked to pay a $63.60 coinsurance for a CPAP device. A CPAP device falls within the Durable 
Medical Equipment (DME) and Related 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 
coinsurance for a CPAP provided from April 11, 2021, to November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on March 4, 2022, to March 
15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for acupuncture services. You say that you had six previous visits with this provider 
and the status was in-network. The Plan denied your request. The Plan says your plan excludes coverage for 
this out-of-network service. 
 
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 acupuncture services provided on March 4, 2022, 
to March 15, 2022, 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 on February 24, 2022. 
 
You asked the Plan to waive the copayment for ambulance. 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 $200 
copayment per one-way trip for ambulance services. Covered ambulance services include fixed wing, rotary 
wing, and ground ambulance services to the nearest appropriate facility that can provide care if they are 
furnished to a member whose medical condition is such that other means of transportation could endanger the 
person's health or if authorized by our plan. 
 
 
 
 
 
 You have been asked to pay a $200 copayment for ambulance. Ambulance 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 on February 24, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the service was provided as per medical necessity of 
the patient. The Plan denied your request. The Plan says the services denied because the Plan did not receive a 
primary care provider referral to review and approve. The Plan also says that the services were billed, rendered, 
and referred by non-participating providers. 
 
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 January 13, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 23, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. 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 March 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Abdominal Aortic Aneurysm (AAA) screening provided 
on April 13, 2022. 
 
You asked the Plan to pay for the AAA screening. You say that you need a second screening due to your prior 
history. The Plan denied your request. The Plan says the benefit for an AAA screening has already been 
exhausted. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. However, the Plan offers an AAA screening benefit 
that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an AAA screening benefit in excess of Medicare coverage, the frequency limit of once 
per lifetime has been exceeded. The record shows that the Plan paid for an AAA screening that you received on 
October 15, 2020. Therefore, we decided that the Plan does not have to pay for the Abdominal Aortic 
Aneurysm (AAA) screening provided on April 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided from October 19, 2021, to 
December 2, 2021. 
 
You asked the Plan to pay for infrared therapy. You say that the infrared therapy is medically necessary. The 
Plan denied your request. The Plan says infrared therapy is considered not reasonable and necessary by 
Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary under section 
1862(a)(1)(A) of the Social Security Act (the Act). 
 
 We looked at the file and Medicare rules. Medicare says that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pay for infrared therapy provided from October 19, 2021, to December 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an inpatient stay provided on January 10, 
2022. 
 
You asked the Plan to waive the deductible for an inpatient stay. You say that you should not have to pay this 
charge. The Plan denied your request. The Plan says the deductible applied was correct, as you had not yet met 
your deductible at that time. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to impatient hospital care. You are 
being asked to pay the remainder of your deductible, which is $279.18. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category impatient 
hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible which applies to impatient hospital care. This cost sharing is a contractual obligation that had not 
been met at the time an inpatient stay was received on January 10, 2022. Therefore, we decided that the Plan 
does not have to waive the deductible for an inpatient stay provided on January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services provided were medically 
necessary. 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 laboratory services 
provided on April 5, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the $350 copayment charged for a diagnostic colonoscopy
provided on September 17, 2021.

You asked the Plan to waive this copayment. You say that you do not believe this bill is correct. The Plan
denied your request. The Plan says your provider submitted this as a diagnostic colonoscopy due to a previous
history of a benign tumor of the colon. This would fall under the outpatient surgical copayment. Maximus
partially overturned the Plans denial stating the Plan contract submitted with the case file shows the copayment
would be $325. The Plan requested a reopen and submitted the correct contract which shows the copayment of
$350.

The Plan is correct in this case. 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 $350 copayment for outpatient surgical services. 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 $350 copayment charged for a diagnostic colonoscopy provided on September 17,
2021.