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

 
We decided that the Plan does not have to waive the copayment for an in-network eye ultrasound provided on 
January 27, 2023. 
 
You asked the Plan to waive the copayment for an in-network eye ultrasound. You say that you should not 
have to pay so much for this 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 a $100 
copayment for Medicare-covered ultrasound.  
 
You have been asked to pay the allowed amount of $11.88 which is less than the $100 copayment for an in-
network eye ultrasound. This item/service falls within the Medicare-covered ultrasound 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 eye ultrasound provided on January 27, 2023.
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 
March 2, 2023, to March 11, 2023. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you did not pay this 
much for this service in the past. 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 $200 
copayment per day, for days 1 to 5 and a $0 copayment after days 5 each time you are admitted to an acute care 
hospital.  
 You have been asked to pay a $200 copayment per day, for days 1 to 5 of the inpatient hospital stay. You have 
been asked to pay a total of $1,000 ($200 copayment x 5 days = $1,000). You have not been charged for any 
additional days. 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 March 2, 2023, to March 
11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laparoscopic hernia repair to be provided while out-of-
area (OOA).  
 
You asked the Plan to pre-approve the OOA hernia repair. You say that it is felt that this surgery should be 
done more quickly and should not be delayed.  The Plan denied your request. The Plan says the enrollee can 
obtain the surgical treatment upon return to the service area. There is no medical need for OOA treatment.  
 
Medicare says that plans must pay for emergency and urgently needed services. The rules say that while 
outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-
approved care.   
 
 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 OOA hernia repair. Our reviewer 
says that the requested OOA surgery is not shown to be either emergent or urgently needed.  Our physician 
reviewer found the need for this surgery was not foreseen and was due to a flare-up of the condition outside the 
service area. However, based on the medical records provided, there is nothing urgent or emergent about the 
hernia repair(s). There is no incarceration or hernia strangulation. Records support that it would be medically 
reasonable to delay the planned hernia surgery until the enrollee returns to the service area, establishes care 
with a local surgeon, and gets the surgery scheduled. 
 
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 OOA hernia repair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a laparoscopic hernia repair to be provided while out-of-area (OOA).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from August 9, 2022, to August 10, 2022
You asked the Plan to waive the copayment for the emergency room visit. You say that you disagree with the charges, and you do not know why you are getting billed. The Plan denied your request. The Plan says that this cost sharing was charged correctly.
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid eligible.
The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services). These services qualified under the Medicaid coverage. The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided from August 9, 2022, to August 10, 2022
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cervical spine x-rays provided on November 11, 2022. 
 
You asked the Plan to pay for cervical spine x-rays. You say that this is supported in the records. 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 cervical spine x-rays 
provided on November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on March 19, 
2023. 
 
You asked the Plan to pay for principal care management services. You say that the enrollee was in a nursing 
home at the time that the services were rendered. 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 principal care 
management services provided on March 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 8, 2023. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan had 
network providers available to perform the services. The only exceptions are emergencies, urgently needed 
care, when the network is not available, out-of-area dialysis services, and cases in which the Plan authorizes 
use of out-of-network 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on March 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on March 07, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that services were not rendered at this 
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 a $44 
copayment for in-network services received from all other specialists. 
 
You have been asked to pay a $44 copayment for an office visit. This item/service falls within the in-network 
services received from all other specialists 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 office visit provided on March 07, 2023.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve monitored anesthesia care (MAC).
You asked the Plan to pre-approve monitored anesthesia care. You say that these services are medically
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage
criteria has not been met.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for monitored
anesthesia care. Our Medical Director states that the available documentation does not support that the enrollee
in this case had a medical condition that would necessitate MAC, or that deep sedation would be required. Our
Medical Director found that your condition does not meet criteria for coverage of monitored anesthesia care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of monitored anesthesia care have not been met. Therefore, we decided that the
Plan does not have to pre-approve monitored anesthesia care (MAC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a one-way routine transportation trip for a total of 96.7 
miles. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the request exceeds the mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation for 12 one-way trips and each one-way trip must not exceed 50 
miles.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you are requesting a 
one-way trip for a total of 96.7 miles. Based on this information, we decided that the Plans rules for coverage 
of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
one-way routine transportation trip for a total of 96.7 miles.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing evaluation services (96132) 
and psychological or neuropsychological test administration and scoring (codes 96136 and 96138). 
 
You asked the Plan to pre-approve neuropsychological testing evaluation services and psychological or 
neuropsychological test administration and scoring. The Plan denied your request. The Plan says 
automated/computerized neuropsychological testing is not reasonable or necessary at this time. 
 
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 neuropsychological testing evaluation 
services and psychological or neuropsychological test administration and scoring. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the available documentation does not support that the neuropsychological testing evaluation 
services are reasonably expected to impact the enrollee's management and outcomes.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing evaluation services and psychological or 
neuropsychological test administration and scoring have not been met. Therefore, we decided that the Plan does 
not have to pre-approve neuropsychological testing evaluation services (96132) and psychological or 
neuropsychological test administration and scoring (codes 96136 and 96138).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 08, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 an office visit provided 
on February 08, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from April 26, 2022, to 
Ma7 25, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. 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 April 26, 2022. The NOA was not received by the Plan until January 16, 
2023. 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 the home health services 
rendered from April 26, 2022, to Ma7 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a respiratory assist device and a humidifier 
provided on March 16, 2023, and April 16, 2023.  
 
You asked the Plan to waive the coinsurance for a respiratory assist device and a humidifier. You say that you 
were told that these items would be fully covered. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each Medicare-covered item.  
 
 
 You have been asked to pay $77.18, which is 20% coinsurance of the allowed amount for each respiratory 
assist device and humidifier provided on March 16, 2023, and April 16, 2023 ($385.88 allowed amount x 20% 
= $77.18). You have been asked to pay a total of $154.36 ($77.18 coinsurance + $77.18 coinsurance = 
$154.36). This item/service falls within the durable medical equipment 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 respiratory assist device and a humidifier provided on 
March 16, 2023, and April 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction of a pre-malignant lesion provided on 
September 13, 2022. 
 
You asked the Plan to pay for the destruction of a pre-malignant lesion. You say that this service was 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). Therefore, we decided that the Plan does not have to pay for the destruction of a pre-
malignant lesion provided on September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 13, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that this is supported in the records. 
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 subsequent nursing 
facility care provided on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a new patient office visit provided on April 
18, 2023. 
 
You asked the Plan to waive the copayment for a new patient office visit. You say that you think that this 
service should be covered. 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 covered in-person or telehealth visit or consultation in an outpatient location with a 
specialist. 
 
You have been asked to pay a $45 copayment for a new patient office visit. This item/service falls within the each covered in-person or telehealth visit or consultation in an outpatient location with a specialist 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. However, the 
Plan is only holding you responsible for a $20 copayment, which is less than the $45 copayment. Therefore, we 
decided that the Plan does not have to waive the copayment for a new patient office visit provided on April 18, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 23, 2023, to 
February 21, 2023. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. 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 January 23, 2023. The NOA was not received by the Plan in a timely 
manner. 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 the home health services 
rendered from January 23, 2023, to February 21, 2023.