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

 
We decided that the Plan does not have to pay for a nursing facility visit provided on November 18, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that I depend on the facility staff to verify 
eligibility and to obtain authorization. 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). There was a priorauthorization, however, the DOS occurred outside of the 
authorization date. Therefore, we decided that the Plan does not have to pay for a nursing facility visit provided 
on November 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on January 12, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home visit provided on 
January 12, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
November 21, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that the Plan should pay 
for this since your provider said you needed it. 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 $325 
copayment for in-network outpatient surgery provided at an outpatient hospital facility. 
 
You have been asked to pay a $325 copayment for the diagnostic colonoscopy. This item/service falls within the in-network outpatient surgery provided at an outpatient hospital facility 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 diagnostic colonoscopy provided on November 21, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 10, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services 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 psychotherapy provided 
on January 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on March 
07, 2023, to March 14, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $500 
copayment for inpatient hospital care. 
 
You have been asked to pay a $500 copayment for inpatient hospital care. 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 copayment for inpatient 
hospital care provided on March 07, 2023, to March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on November 09, 2022. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
November 09, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ambulance transportation provided on 
December 07, 2022. 
 
You asked the Plan to reduce the copayment for the ambulance transportation. You say that the copayment is 
excessive. 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 ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance transportation. This item/service falls within 
the ambulance 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 reduce the copayment for the 
ambulance transportation provided on December 07, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Melanoma testing provided to the enrollee on May 13, 2022.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the medical records provided show the enrollee has malignant melanoma of the left forearm. The enrollee was not undergoing workup or being evaluated for treatment nor has metastatic disease been ruled out. Therefore, all of the required criteria were not met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare requires all criteria listed in the LCD be met for coverage of this testing. Based on the records provided, Part 1b and 1c of the applicable LCD have not been met. Therefore, we decided that the Plan does not have to pay for Melanoma testing provided to the enrollee on May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 22, 2022, to March 30, 
2022. 
 
You asked the Plan to pay for an office visit. You say that the services 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 an office visit provided 
on March 22, 2022, to March 30, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on January 13, 2023. 
 
You asked the Plan to pay for psychotherapy services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy services 
provided on January 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab and venipuncture services, and an electrocardiogram 
(ECG) provided on January 12, 2023. 
 
You asked the Plan to pay for lab and venipuncture services, and an electrocardiogram (ECG). 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 lab and venipuncture 
services, and an electrocardiogram (ECG) provided on January 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital stays, and 
emergency room visit provided from November 30, 2022, to January 17, 2023. 
 
You asked the Plan to waive the copayments for the inpatient hospital stays, and emergency room visit. You 
say that you were misdiagnosed and feel 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 2022 contract with the Plan clearly says that you must pay a 
$195 copayment per day for days 1-7 of each inpatient hospital stay. Your 2022 contract with the Plan also 
says that you must pay a $75 copayment for each emergency room visit. Your 2023 contract with the Plan also 
says you must pay a $175 copayment per day for days 1-7 of each inpatient hospital stay.  
 
You have been asked to pay a $195 copayment per day for days 1-7 of the inpatient hospital stay provided from 
November 30, 2022, to December 9, 2022. This item/service falls within the inpatient hospital care benefit 
category. You have not been charged after day seven or for the day you were discharged. You have been asked 
to pay a total of $1,365 for this inpatient hospital stay ($195 copayment per day x 7 days = $1,365).  
 
You have also been asked to pay a $75 copayment for the emergency room visit provided on December 16, 
2022. This item/service falls within the emergency care benefit category.  
 
Due to meeting your out-of-pocket maximum you have been asked to pay $369.75, which is less than the 
standard $195 copayment per day for days 1-3 of the inpatient hospital stay provided from December 26, 2022, 
to December 29, 2022. This item/service falls within the inpatient hospital care benefit category.  
 
You have also been asked to pay a $175 copayment per day for days 1-5 of the inpatient hospital stay provided 
from January 12, 2023, to January 17, 2023. This item/service falls within the inpatient hospital care benefit 
category. You have not been charged after day seven or for the day you were discharged. You have been asked 
to pay a total of $875 for this inpatient hospital stay ($175 copayment per day x 5 days = $875). 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, and emergency room visit provided 
from November 30, 2022, to January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for covid-19 testing provided on October 20, 2022. 
 
You asked the Plan to pay for covid-19 testing. 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 covid-19 testing 
provided on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Prolia injection provided on March 29, 
2023. 
 
You asked the Plan to waive the coinsurance for the Prolia injection. You say that you would like to contest 
this 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 20% 
coinsurance for in-network or out-of-network Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the Prolia injection. This item/service falls within the in-
network or out-of-network Medicare Part B drugs 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 total you owe is $276.84 ($1,384.20 allowed amount  x 20% 
coinsurance = $276.84). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
Prolia injection provided on March 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital stay provided on September 02, 2022, to 
September 09, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for inpatient hospital stay. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says while the Plan offers a Point-of-Service option for coverage of out-of-
network services, this benefit only applies to dental services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for inpatient hospital stay provided on September 02, 
2022, to September 09, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on January 20, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
January 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 5, 2022, to June 
7, 2022.  
 You asked the Plan to pay for the home health services. 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. 
 
We looked at the file and the rules. The claim was billed with a type of bill 324. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from June 5, 2022, to June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the denosumab injection, and the 
administration of the injection provided by an in-network provider on August 11, 2022. 
 
You asked the Plan to waive the cost sharing for the injection and the administration. You say that you think 
that the cost sharing 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 20% 
coinsurance for in-network Medicare Part B covered drugs, as well as the administration, provided at all 
locations of service. You have been asked to pay a $720 coinsurance for the injection and the administration ($3600 allowed 
amount x .20 = $720). These items/services fall within the Medicare Part B prescription drugs 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 cost sharing for the denosumab injection, and the administration of the 
injection provided by an in-network provider on August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided on 
February 28, 2023. 
 
  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as they were not 
rendered on the basis of a covered diagnosis. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services provided in this case were 
not rendered on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not 
have to pay for the acupuncture treatments (97810, 97811) provided on February 28, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the defibrillator replacement surgery 
provided on August 15, 2022, to August 16, 2022. 
 
You asked the Plan to waive the copayment for the defibrillator replacement surgery. You say that you were 
not informed of the copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 
copayment for in-network outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $395 copayment for the defibrillator replacement surgery. This item/service falls within the in-network outpatient surgery, including services provided at hospital outpatient facilities 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 
the Plan had reprocessed the claim at the in-network benefit level. Therefore, we decided that the Plan does not 
have to waive the copayment for the defibrillator replacement surgery provided on August 15, 2022, to August 
16, 2022.