Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections on June 16, 2022. 
 
You asked the Plan to waive the copayment for injections. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 
copayment for Medicare-covered non-surgical visit in an outpatient clinic after you meet you $395 deductible. 
Covered services including but are not limited to services in an emergency department or outpatient clinic, such 
as observation services or outpatient surgery.  
 
You have been asked to pay a $395 copayment for injections. 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 injections on June 
16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visit on February 15, 2022. 
 
You asked the Plan to waive the deductible for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $203 deductible which applies to Physician/practitioner services, 
including doctor's office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/practitioner 
services, including doctor's office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $203 deductible which applies to Physician/practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time 
office visit was received on February 15, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for office visit on February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic lab services and specialist office 
visit June 22, 2022. 
 
You asked the Plan to waive the copayment for diagnostic lab services and specialist office visit. You say that 
you disagree with the copayments. 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 $5 
copayment and a $35 copayment for Outpatient hospital services/lab services and physician/practitioner 
services/specialist visit.  
 
You have been asked to pay a $5 copayment for diagnostic lab services and a $35 copayment and specialist 
office visit. The total amount you are being asked to pay is $40 ($35 + $5 = $40). 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 diagnostic lab services and specialist office visit June 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for eye surgery provided on September 13, 
2022, and September 20, 2022. 
 
You asked the Plan to reduce the copayment for eye surgery. You say that you do not understand why you were 
required to pay $1,125 before each procedure and a $245 copayment for each visit. 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 $245 
copayment for surgery services in an ambulatory surgical center.  
 
You have been asked to pay a total copayment of $490 for eye surgery ($245 per visit x 2 visits = $490). This 
item/service falls within the Outpatient Surgery 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 eye surgery provided on September 13, 2022, and September 20, 2022.  
 Your complaint about paying $1,125 prior to each procedure is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for visit for outpatient hospital service 
provided on June 8, 2022. 
 
You asked the Plan to waive the copayment for visit for outpatient hospital service. You say that you are 
disputing the share cost. 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 $250 
copayment for outpatient hospital services.  
 
You have been asked to pay $250 copayment for visit for outpatient hospital service. 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 
visit for outpatient hospital service provided on June 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health care services 
provided on February 25, 2022, to March 22, 2022. 
 
You asked the Plan to waive the copayment for inpatient mental health care services. You say that you are 
disputing the share cost. 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 $275 
copayment per day for days 1 to 5 for inpatient mental health care. This inpatient mental health care stay lasted 
25 days, resulting in a copayment amount of $1,375 ($275 per day for 5 days = $1,375).  
 
You have been asked to pay $275 copayment per day for days 1 to 5 for inpatient mental health care services. 
This item/service falls within the inpatient mental health 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 mental health care services provided on February 25, 2022, to March 22, 
2022.  
 
Your complaint about being discharged too early is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nuclear medicine and stress test provided 
on June 2, 2022. 
 
You asked the Plan to waive the copayment for nuclear medicine and stress test. You say that you are disputing 
the share cost. 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 $5 and 
$75 copayments for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $5 and $75 copayments for nuclear medicine and stress test. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for nuclear medicine and stress test provided on June 2, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on July 22, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you are disputing the share cost. 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 $170 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $114.55, which is less than the $170 copayment for ultrasound. 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 ultrasound provided on July 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 11, 2022 to 
March 12, 2022. 
 
You asked the Plan to pay for home health services. You say that the NOA was submitted. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 11, 2022. The NOA was not received by the Plan until April 29, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from February 11, 2022 to March 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periapical first radiographic image (D0220), resin-
based composite one surface anterior (D2330), resin-based composite-one surface posterior (D2391) x3, 
amalgam-two surfaces primary or permanent (D2150), prophylaxis-adult (D1110), periodic oral evaluation 
established patient (D0120), amalgam-one surface primary or permanent (D2140) x2 provided on June 9, 2022, 
to July 19, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were not told the provider was out-of-
network, if you would have known you would not have used them. The Plan denied your request. The Plan 
says you are responsible for any charged amount above the Plans cost-sharing amount when your services are 
received from an out-of-network provider. 
 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment.  
 
Date of 
Service 
Dental code Provider 
Billed 
Allowed 
(MAC) 
Plan Paid Member 
Cost-share 
Amt Greater 
than MAC 
Total 
Member 
Liability 
June 9, 2022 D0220 $70 $14 $14 $0 $56 $56 
June 16, 2022 D2330 $165 $79 $79 $0 $86 $86 
June 16, 2022 D2391 $185 $84 $84 $0 $101 $101 
June 16, 2022 D2391 $185 $84 $84 $0 $101 $101 
June 20, 2022 D2391 $185 $84 $84 $0 $101 $101 
June 20, 2022 D2150 $185 $80 $80 $0 $100 $100 
June 27, 2022 D1110 $150 $50 $50 $0 $100 $100 
June 27, 2022 D0120 $55 $24 $24 $0 $31 $31 
July 19, 2022 D2140 $165 $62 $62 $0 $103 $103 
July 19, 2022 D2140 $165 $62 $62 $0 $103 $103 
TOTAL:       $882 
 
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 pay more for periapical first radiographic image (D0220), resin-based 
composite one surface anterior (D2330), resin-based composite-one surface posterior (D2391) x3, amalgam-
two surfaces primary or permanent (D2150), prophylaxis-adult (D1110), periodic oral evaluation established 
patient (D0120), amalgam-one surface primary or permanent (D2140) x2 provided on June 9, 2022, to July 19, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services one hour a day, seven days a 
week. 
 
You asked the Plan to pre-approve the aide services. You say that your medical condition has deteriorated, and 
you need more time each day with aide services. The Plan denied your request. The Plan says that the 
additional one hour of aide services is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found that the clinical 
documentation shows you were recently evaluated by your primary care provider. There is no documentation 
of any clinical or functional status change to warrant the increase of home health aide services. 
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide services one hour a day, seven days a week.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 4, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met.
Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and stated that the records show the specimen was collected on November 5, 2021, rather than the billed date of service February 4, 2022. The date of service for a clinical laboratory test or the technical component of physician pathology service must be the date the specimen was collected.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed due to billing discrepancies with the specimen collection dates reported. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller upgrade (E2377) harness 
upgrade (E2313) electronic connection between 2 or more power systems (E2311).  
You asked the Plan to pre-approve the upgraded electronics. You say that you are requesting the denial be 
reconsidered so you can provide the enrollee with the appropriate medical equipment to meet their medical 
needs. 
 The Plan denied your request. The Plan says although there are three approved power options on this 
wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options 
through the joystick. 
 
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 the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found In this case, the enrollee has a neurologic disorder with functional deficits. The 
criteria for a power wheelchair are met. The requested electrical accessories are not medically necessary as the 
enrollee does have use of the upper extremity and can operate and control the power options using the switches 
that are included in the basic wheelchair. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the expandable controller upgrade (E2377) harness upgrade (E2313) electronic 
connection between 2 or more power systems (E2311).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (genetic testing) provided to the enrollee on October 31, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial stating the service was medically necessary. The Plan requested a reopen and stated the issue was not medical necessity but the fact that the claim had billing errors. The Plan states the date of service for a clinical laboratory test, or the technical component of physician pathology service must be the date the specimen was collected. The Plan states based on the records provided, there are issues with the dates reported.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim created payment issues due to the dates billed and the billing requirements regarding specimen collection. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (genetic testing) provided to the enrollee on October 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 3, 2022. 
 
You asked the Plan to pay for the services provided. You say that you did not require their services. The Plan 
denied your request. The Plan says the billed service is excluded from coverage. 
 
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 February 3, 2022. When there is no transport, 
neither Medicare nor the Plan pays for the services provided. Per authority granted under the American Rescue 
Plan Act of 2021, the Centers for Medicare and Medicaid Service (CMS) has waived the requirements that an 
ambulance service must include transport to allow for treatment in place when transportation was not provided 
based on community-wide emergency medical service (EMS) protocols. However, this requires that the 
ambulance provider submit a claim for payment under this waiver. You may wish to contact the ambulance 
provider in this case to request that a new claim be submitted for payment. Therefore, we decided that the Plan 
does not have to pay for the ambulance services provided on February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service June 30, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says code 99153 is not payable in the facility 
setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service June 30, 2022, billed with 
code 99153.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit (99442) provided on September 14, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth visit. You say that it was not possible for us to get the authorization 
before the service was rendered. The Plan denied your request. The Plan says prior authorization was not 
obtained. 
 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 in this case is not a network provider with the Plan. 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 the telehealth visit (99442) provided on September 14, 2022, by 
an out-of-network (OON) provider.