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

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on 
September 5, 2022. 
 
You asked the Plan to pay for the blood smear services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, this service was billed with a 
place of service of 22 (outpatient hospital). This code has a indicator of "8". This indicator identifies the 
professional component of clinical laboratory codes for which separate payment may be made only if the 
physician interprets an abnormal smear for hospital inpatient. No payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients.  
 
 The physician interpretation is paid through the clinical laboratory fee schedule payment for the clinical 
laboratory test. Based on this information, we decided that Medicare rules for coverage of the blood smear 
services have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear 
services coded 85060 provided on September 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the specialist office visit, the joint injection, 
and the triamcinolone acetonide injection provided by an out-of-network provider on August 4, 2022. 
 
You asked the Plan to waive the deductible for the specialist office visit, the joint injection, and the injection. 
You say that you were unaware that the provider was out-of-network. 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. Your 
contract with the Plan says that you must pay the full cost for most covered services until you have paid your 
$750 deductible, and the deductible applies to all out-of-network services besides annual routine physical 
exams, certain Medicare-covered preventative services, and emergency care and urgently needed services. 
 
You have been asked to pay a $215.68 deductible for the specialist office visit, the joint injection, and the 
injection ($132.52 allowed amount + $78 allowed amount + $5.16 allowed amount = $215.68 deductible). The 
items or services you asked the Plan to waive the deductible for were provided by an out-of-network provider. 
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to physician/practitioner services, including doctors office visits, outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers, and Medicare Part B 
prescription drugs. This cost sharing is a contractual obligation that had not been met at the time the specialist 
office visit, the joint injection, and the triamcinolone acetonide injection were received on August 4, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for the specialist office visit, the joint 
injection, and the triamcinolone acetonide injection provided by an out-of-network provider on August 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on October 17, 2022. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home health services 
provided on October 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network jaw x-ray provided on 
September 20, 2022. 
 
You asked the Plan to waive the copayment for an out-of-network jaw x-ray. You say that you should not have 
a copayment for this as the provider is in-network. 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 an out-of-network jaw x-ray. 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 an out-of-network jaw x-ray provided on September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee immobilizer provided on September 23, 2022. 
 
You asked the Plan to pay for the knee immobilizer. You say that you are not part of the hospital and 
authorization cannot be obtained. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the knee immobilizer 
provided on September 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on October 10, 2022. 
 
You asked the Plan to pay for a home health visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home health visit 
provided on October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the dermatology visit provided by an in-
network provider on March 15, 2022. 
 
You asked the Plan to waive the copayment for the dermatology visit. You say that you don't agree with the 
cost sharing. 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 $35 
copayment for specialist physician services. 
 
You have been asked to pay a $35 copayment for the dermatology 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 copayment for the dermatology visit provided by an in-network provider on March 15, 2022.  
 Maximus read your letter and knows that you may have a question regarding your enrollment in the Plan. 
Maximus cannot answer enrollment questions. Maximus is sending a copy of your case file and your letter to 
the Philadelphia CMS Regional Office so that it can look into your enrollment question.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on July 5, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for drug testing. 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 drug testing provided on July 5, 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 Botox injections provided on August 31, 2022. 
 
You asked the Plan to pay for Botox injections. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for Botox injections 
provided on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on June 
28, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. You say that you disagree with the 
copaymet. 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/Medicare-covered outpatient diagnostic tests. 
 
You have been asked to pay a $10 copayment for outpatient diagnostic tests. This item/service falls within the 
outpatient diagnostic tests/Medicare-covered outpatient diagnostic tests 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 outpatient diagnostic tests provided on June 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 16, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim was submitted with Medicare-
approved codes. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Please note that the referring provider in this case is also out-of-network with the 
Plan. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
November 16, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) visit 
provided on October 07, 2022, to October 08, 2022. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) visit. You say that this 
was an emergency and you should not have to pay this 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 $65 
copayment for emergency care. 
 
You have been asked to pay a $65 copayment for an in-network emergency room (ER) visit. 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 
an in-network emergency room (ER) visit provided on October 07, 2022, to October 08, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 13, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Please note that the referring provider in this case is also out-of-network with the 
Plan. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic eye appointment 
provided on September 21, 2022. 
 
You asked the Plan to waive the copayment for an in-network diagnostic eye appointment. You say that you 
should not have a copayment for this visit as it is a screening exam. 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 for vision care. 
 
You have been asked to pay a $40 copayment for an in-network diagnostic eye appointment. This item/service 
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 an in-
network diagnostic eye appointment provided on September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 1, 
2022, to September 9, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service September 1, 2022, to September 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on September 05, 
2022. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that this was medically necessary and 
should be covered. The facility did not get the proper documentation. The Plan denied your request. The Plan 
says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a skilled nursing facility 
visit provided on September 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for methadone treatments provided on July 04, 2022. 
 
You asked the Plan to pay for methadone treatments. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for methadone treatments 
provided on July 04, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-rays provided on October 14, 2022. 
 
You asked the Plan to pay for the knee x-rays. You say that this was an ER admission and authorization should 
not be required. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the knee x-rays provided 
on October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network dermatological 
(specialist) procedure provided on July 06, 2022. 
 
You asked the Plan to waive the copayment for an out-of-network dermatological (specialist) procedure. You 
say that this should not be coded as 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 $250 
copayment for outpatient hospital services. 
 
You have been asked to pay a $250 copayment for an out-of-network dermatological (specialist) 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 an out-of-network dermatological (specialist) procedure provided on July 06, 2022.