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

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
July 30, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you disagree with 
the copayment applied and the services received were medically necessary. 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for an 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 emergency room 
(ER) visit provided on July 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for in-network photo chemotherapy provided 
on June 29, 2023. 
 
You asked the Plan to waive the deductible for in-network photo chemotherapy. You say that you were told 
this person was in-network. You should only have a $45 copayment for this service. 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 $1000 deductible which applies to physician/practitioner services, 
including doctors office visits.  
 
You have been asked to pay $131.80 from this visit, towards your 2023 deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1000 deductible which applies to  physician/practitioner services, including doctors office visits. This cost sharing is a contractual obligation that 
had not been met at the time in-network photo chemotherapy was received on June 29, 2023. Therefore, we 
decided that the Plan does not have to waive the deductible for in-network photo chemotherapy provided on 
June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation, intraoral x-rays, and 
bitewing x-rays (D0220, D0150, D0274, D0230) provided on May 25, 2023. 
 
You asked the Plan to pay more for 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Your benefit for intraoral x-rays was exhausted on the appealed claim. 
 
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. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally, the record indicates your benefit for intraoral x-rays exhausted on the appealed claim. Therefore, 
we decided that the Plan does not have to pay more for a comprehensive oral evaluation, intraoral x-rays, and 
bitewing x-rays (D0220, D0150, D0274, D0230) provided on May 25, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
July 22, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you were advised 
that there would be no copayment for the ER 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 $95 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $95 copayment for an emergency room (ER) visit. This item/service falls within 
the 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 an 
emergency room (ER) visit provided on July 22, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network punch biopsy procedure 
provided on June 15, 2023. 
 
You asked the Plan to waive the copayment for an in-network punch biopsy procedure. You say that you paid 
an office visit copayment already. Why are you paying more? 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 for laboratory services. 
 
You have been asked to pay a $200 copayment for an in-network punch biopsy procedure. This item/service 
falls within the laboratory 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 in-network punch biopsy procedure provided on June 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on July 
30, 2023, to August 07, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not admitted 
to the intensive care unit. 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 inpatient hospital care. 
 
You have been asked to pay a $65 copayment for the inpatient hospital stay. 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. You have been asked to pay a total of $325 for the inpatient hospital stay ($65 copayment 
x 5 days = $325). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital stay provided on July 30, 2023, to August 
07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 29, 2023. 
 
You asked the Plan to pay for an office visit. You say that you would like the plan to reconsider the original 
determination. 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 June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Global Reach cancer genetic panel provided to the
enrollee on April 10, 2022.

You asked the Plan to pay for the Global Reach cancer genetic panel. You say that this should be paid for. The
Plan denied your request. The Plan says that this denial was appropriate given the clinical scenario. Maximus
overturned the Plan's denial. The Plan requested a reopen and stated that Maximus did not apply the billing
criteria included in the case file and provided documentation showing billing of multiple codes to the same
specimen. The Plan demonstrated that the enrollee was billed for this testing with multiple codes all taken from
one specimen. This is not allowed by Medicare. The expectation is one claim, from samples taken from one
specimen when this type of genetic testing is being performed.

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 being billed for the same
specimen and the same form of testing. Medicare rules for coverage of this claim as billed have not been met.
Therefore, we decided that the Plan does not have to pay for the Global Reach cancer genetic panel provided to
the enrollee on April 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a magnetic resonance imaging (MRI) 
provided on August 02, 2023. 
 
You asked the Plan to reduce the copayment for a magnetic resonance imaging (MRI). You say that you feel 
the copayment is excessive and should be reduced. 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 $225 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $225 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the 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 reduce the copayment 
for a magnetic resonance imaging (MRI) provided on August 02, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram provided on June 20, 
2023. 
 
You asked the Plan to waive the copayment for an electrocardiogram. You say that this service should 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 a $225 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $225 copayment for an electrocardiogram. This item/service falls within the in-
network 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. However, since the allowed amount is 
less than the standard copayment, you only owe $55.23. Therefore, we decided that the Plan does not have to 
waive the copayment for an electrocardiogram provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography provided on January 11, 2023. 
 
You asked the Plan to pay for computed tomography. You say that this service 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 computed tomography 
provided on January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the remote monitoring provided on 
February 20, 2023, to April 12, 2023. 
 
You asked the Plan to pay for the office visit and the remote monitoring. 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 the office visit and the 
remote monitoring provided on February 20, 2023, to April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for on office visit provided on August 02, 2023. 
 
You asked the Plan to pay for on office visit. You say that you were fatigued and need this 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 on office visit provided 
on August 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telemedicine visit provided on January 09, 2023. 
 
You asked the Plan to pay for a telemedicine visit. You say that this provider is in-network. 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 telemedicine visit 
provided on January 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous infusion provided on July 20, 2023. 
 
You asked the Plan to pay for intravenous infusion. You say that you are asking for the medical documents to 
be reviewed. 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 intravenous infusion 
provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99223 billed to the enrollee for January 16,
2023.

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. The
Plan requested a reopen and noted that this claim denied because this service was billed with an inappropriate
diagnosis code. The appealed claim was billed with diagnosis code I60.9 for Nontraumatic subarachnoid
hemorrhage, unspecified which is an excluded code.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, this claim could
not be paid due to the submission of an invalid code. There is a more appropriate code used by Medicare for
these services. Therefore, we decided that the Plan does not have to pay for procedure code 99223 billed to the
enrollee for January 16,2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on July 21, 2023. 
 
You asked the Plan to pay for procedure code J3490. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered 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. 
 
In this case, the CPT Code Manual definition of code J3490 is Unclassified drugs. We find that CPT code 
J3490 is not supported. Code J3490 was billed to identify Bupivacaine, which is a local anesthetic. If 
performed to facilitate the infusion or injection or hydration, the use of local anesthesia is included and not separately billable. Based on this information, we decided that Medicare rules for coverage of procedure code 
J3490 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 
provided on July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network photo chemotherapy visit 
provided on June 27, 2023. 
 
You asked the Plan to waive the deductible for an in-network photo chemotherapy visit. You say that this 
should be a $45 copayment, not this large 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. Your 
contract with the Plan says that there is a $1000 deductible which applies to physician/practitioner services 
including doctor's office visits.  
 
Youve been asked to pay $131.80 towards this 2023 deductible. 
 
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 $1000 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 an 
in-network photo chemotherapy visit was received on June 27, 2023. Therefore, we decided that the Plan does 
not have to waive the deductible for an in-network photo chemotherapy visit provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmic diagnostic imaging and a 
specialist office visit provided on July 24, 2023. 
 
You asked the Plan to waive the copayment for ophthalmic diagnostic imaging and a specialist office visit. You 
say that you saw an ophthalmologist not a specialist. You also say that this should have processed with a $0 
copayment for being seen at a primary care doctors office. 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 $30 
copayment for therapeutic radiology services and a $15 copayment for specialist office visit or outpatient 
facility visits for diagnostic procedures and tests.  
You have been asked to pay a $30 copayment for ophthalmic diagnostic imaging and a specialist office visit. 
This item/service falls within the therapeutic radiology services and a $15 copayment for specialist office visit 
or outpatient facility visits for diagnostic procedures and 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. The record shows that the rendering provider is an 
in-network vision specialist provider. Therefore, we decided that the Plan does not have to waive the 
copayment for ophthalmic diagnostic imaging and a specialist office visit provided on July 24, 2023.