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

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
November 7, 2022, to November 13, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the hospital stay was 
the result of a fall in the emergency room and should not have any charge. 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 $275 
copayment per day for days 1-5 of each inpatient hospital stay.  
 
You have been asked to pay a $275 copayment per day for the inpatient hospital stay. You have been asked to 
pay a total of $1,375 ($275 copayment per day x 5 days = $1,375). You have not been charged past day 5 and 
have not been charged for the day of discharge. These items/services fall 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 the inpatient hospital stay 
provided from November 7, 2022, to November 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Periodontal scaling and root planing, maxillary and 
mandibular partial dentures (D4341, D5213, D5214). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 2, 2018 (D5213, 
D5214) October 15, 2022 (D4341). Therefore, we decided that the Plan does not have to pre-approve 
Periodontal scaling and root planing, maxillary and mandibular partial dentures (D4341, D5213, D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on December 05, 
2022. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. You say that per department there is no 
authorization required for the clinic visit. 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 hospital outpatient 
clinic visit provided on December 05, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided 
on October 13, 2022. 
 
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you should 
have been notified of the cost ahead of time by the provider. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for each Medicare-covered advanced radiology service.  
 
You have been asked to pay a $125 copayment for the myocardial perfusion imaging. 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 the myocardial perfusion imaging provided on October 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from 
August 17, 2022, to August 26, 2022. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that the copayment for this 
service 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 $275 
copayment per day, for days 1-5, and $0 after day 5. 
 
You have been asked to pay a $1375 copayment for the inpatient hospital stay ($275 x 5 days = $1375). 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 reduce the 
copayment for the inpatient hospital stay provided from August 17, 2022, to August 26, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 81345 provided on August 28, 2022. 
 
You asked the Plan to pay for procedure code 81345. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for procedure code 81345 by a contract provider. The file does not show that the plan 
provided notice that procedure code 81345 would not be covered. Under Medicare rules, this means procedure 
code 81345 is considered approved by the plan. Furthermore, the Plan decided to overturn their denial of 
payment for the remaining labs as meeting criteria for plan directed care. Therefore, we decided that the Plan 
has to pay for procedure code 81345 provided on August 28, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing provided on October 11, 2022. 
 
You asked the Plan to pay for laboratory drug testing. 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 laboratory drug testing 
provided on October 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the endoscope exam of the bladder 
provided on October 17, 2022. 
 
You asked the Plan to reduce the copayment for the endoscope procedure. You say that you believe this 
procedure should be under a different benefit category. 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 each out-of-network Medicare-covered surgery.  
 
According to Medicare, the endoscope procedure (code 52000) is considered a surgical procedure. You have 
been asked to pay a $250 copayment for the endoscope procedure. 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 the endoscope exam of the 
bladder provided on October 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(A4239, E2103). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as you do not meet the clinical 
requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not take insulin. 
Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and 
supplies (A4239, E2103).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance provided on August 26, 2022. 
 
You asked the Plan to pay for ambulance. 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 ambulance provided on 
August 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve manual wheelchair to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve manual wheelchair. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be covered. This means that the 
enrollee will have to pay the provider in full for the services furnished. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
manual wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on November 30, 2022. 
 
You asked the Plan to pay for chiropractic care. You say that you were unaware this was an out-of-network 
service. 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 chiropractic care 
provided on November 30, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the knee (73722). 
 
You asked the Plan to pre-approve an MRI of the knee. You say that you would like the Plan's denial to be 
reconsidered. The Plan denied your request. The Plan says that this request does not meet the Medicare or 
health plan coverage criteria. 
 
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 an MRI of the knee. Our reviewer says 
that an MRI of the knee is medically reasonable and necessary for the enrollee. Our physician reviewer found 
the enrollee has sudden onset of left knee pain with popping sensation. Left knee series of March 15, 2023, 
showed degenerative changes and a joint effusion. Our reviewer also found that the presence of the joint 
effusion amounts to a red flag and provides a valid indication for an MRI without a trial of physical therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the knee have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance imaging (MRI) of the knee (73722).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital stays provided from 
January 17, 2022, to September 22, 2022. 
 
You asked the Plan to waive the copayments for the inpatient hospital stays. You say that you want these 
charges waived because you had first gone to the emergency room before being admitted. 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 $150 
copayment for each in-network inpatient hospital admission.  
 
You have been asked to pay a $150 copayment for each inpatient hospital stay. You have been asked to pay a 
total of $450 ($150 copayment for each stay x 3 stays = $450). 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 copayments for the inpatient hospital stays 
provided from January 17, 2022, to September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay additional reimbursement for eyewear purchased on May 4, 2022.
You say that the Plan should cover more of this bill. The Plan denied your request. The Plan says the
appropriate benefit was applied. Maximus overturned the Plans denial. The Plan requested a reopen and
provided additional documentation. The Evidence of Coverage explains that enrollees are responsible for any
amount over the $300 retail price for the frames and lens package through the vision benefit carrier. The Plan
has paid $343.20 towards this eyewear, which is more than the allowed amount. The Explanation of Benefits
shows the provider billed $516.00, the Plan paid $180 and applied the provider discount of $163.20, leaving the
$172.80 as enrollee liability.
The Plan is correct in this case. Medicare does not cover routine vision and eyewear services. However, the
Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's
coverage rules apply in this case. The Plan has demonstrated they have paid more than the $300 benefit.
Based on this information, we decided the Plan does not have to pay for eyewear purchased on May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on June 
29, 2021.  
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you never received this 
service, and you should not have to pay. 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 $45 
copayment for each specialist office visit.  
 
The medical record shows you had a specialist office visit on June 29, 2021. You have been asked to pay a $45 
copayment for the specialist office visit. This item/service falls within the physician/practitioner services, 
including doctor's 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 
specialist office visit provided on June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPAP provided on October 28, 2022. 
 
You asked the Plan to pay for CPAP. 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 CPAP provided on 
October 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve physical therapy visits. You say that the out-of-network provider is very 
close to your home, and you cannot afford to pay the cab service to go to the in-network provider. You also say 
you are unable to sit on an access bus for approximately 2 hours. The Plan denied your request. The Plan says 
you must receive your care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy visits to be provided by an OON provider.