Persius/hicric huggingface dataset:
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 
October 10, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. 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 $40 
copayment for in-network physician services, including an in-person specialist visit. 
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
in-network physician services, including an in-person specialist visit 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 October 10, 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 May 
28, 2023, to May 31, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were misdiagnosed 
at an urgent care center. 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 inpatient hospital care. 
 
You have been asked to pay a $225 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 $675, which is a $225 copayment for three days of inpatient 
hospital care ($225 copayment x 3 days = $675). You have not been charged for the day of discharge. 
Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay 
provided on May 28, 2023, to May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthoses billed for date of service August 18, 2023. 
 
You asked the Plan to pay for the billed items. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The medical records do not show that knee orthoses were part of the enrollees treatment plan. The 
records do not show that the indications for coverage of a knee orthosis have been met. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the knee orthoses billed for date of service August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the epidural injection provided on November 4, 2021. 
 
You asked the Plan to pay for the injection. You say that this claim was filed late due to the national 
emergency. The Plan denied your request. The Plan says the timely filing limit for this claim has expired. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the injection was not filed until March 29, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the epidural injection provided on November 4, 2021.
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 
October 05, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be 
responsible for this copayment for being seen by provider for five minutes. 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 physician/practitioner services, including an in-person specialist visit. 
 
You have been asked to pay a $30 copayment for the specialist office visit. This item/service falls within the physician/practitioner services, including an in-person specialist visit 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 October 05, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the eye surgery on August 30, 2023.  
 
You asked the Plan to waive the cost share for the eye surgery. You say that you are requesting reconsideration 
stating you had to have the surgery performed a second time when a piece of the lens broke and don't feel that 
you should be responsible for a second 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 $295 
copayment for surgery services at outpatient hospital. For the service, the plan/benefit exclusion is $0.10. For 
the service it's $0.10 + $295 = $295.10. Therefore, results in the total cost sharing amount of $295.10. 
 
 You have been asked to pay a $295.10 cost share for the eye surgery. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 share for the eye surgery on August 30, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the collagen dressing provided on 
September 13, 2023. 
 
You asked the Plan to waive the coinsurance for the collagen dressing. You say that you were never told about 
the expense for the post-surgical dressing. 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 durable medical equipment. 
 
You have been asked to pay 20% coinsurance for the collagen dressing. This item/service falls within the 
durable medical equipment 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 $1,062.98 ($5,314.89 allowed amount x 20% = $1,062.98). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the collagen dressing provided 
on September 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on July 
24, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a pneumatic compression device. You say that kindly find the attached 
documents for review which proves the medical necessity for the billed services and process the claims for 
payment. The Plan denied your request. The Plan says enrollees must receive their medical services from an 
in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 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 a pneumatic compression device (E0675) provided 
on July 24, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye surgery provided on September 15, 
2023. 
 
You asked the Plan to waive the copayment for eye surgery. You say that you were advised there was not a 
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 $350 
copayment for outpatient surgery, including services provided athospital outpatient facilities and ambulatory 
surgicalcenters. 
 
You have been asked to pay a $350 copayment for eye surgery. This item/service falls within the outpatient surgery, including services provided athospital outpatient facilities and ambulatory surgicalcenters 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 $350 copayment for an outpatient surgery. Therefore, we decided that the Plan does not have to 
waive the copayment for eye surgery provided on September 15, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility provided on July 02, 
2023, to July 21, 2023. 
 
You asked the Plan to waive the copayment for skilled nursing facility. You say that you are requesting a 
reconsideration of payment for services rendered. 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 $525 
copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $525 copayment for skilled nursing facility. This item/service falls within the Skilled nursing facility (SNF) 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 $525 for the skilled nursing facility (SNF) 
stay ($75copayment x 7 days = $525). Therefore, we decided that the Plan does not have to waive the 
copayment for skilled nursing facility provided on July 02, 2023, to July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for code 77002 billed to the enrollee for February 1, 2023.

You asked the Plan to pay this claim as. 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 stated that
Maximus did not apply the correct billing criteria. The Plan noted that per the National Corrective Coding
Initiative (NCCI) manual Chapter 9, Section G, point, only 1 unit of CPT code 77002 is allowed for a single
patient encounter regardless of the number of needle placements performed and number of localizations.
Therefore, 2 units of 77002 for the billed date of service is not supported. The Plan submitted the billing
guideline and the claims for further review.

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 the number of units allowed
for code 77002 per enrollee per encounter. 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 procedure code 77002 billed to the enrollee
for February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on August 08, 2023. 
 
You asked the Plan to pay for the office visit (99214). You say that the 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 office visit (99214) 
provided on August 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an implantable joint device, the knee 
arthroplasty, and the anesthesia services provided on June 16, 2021 
 
You asked the Plan to reduce the coinsurance for an implantable joint device, the knee arthroplasty, and the 
anesthesia services. You say that you did not have to 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 20% 
coinsurance for outpatient hospital services.  
 
 
 You have been asked to pay 824.16, which is 20% coinsurance of the allowed amount for an implantable joint 
device ($4,120.80 allowed amount x 20% = $824.16). You have also been asked to pay $521.45, which is 20% 
coinsurance of the allowed amount for the arthroplasty procedure ($2,607.26 allowed amount x 20% = 
$521.45). You have also been asked to pay $20.27, which is less than 20% coinsurance of the allowed amount 
for the anesthesia services. These items/services fall within the outpatient hospital services benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce the coinsurance for an implantable joint device, the knee arthroplasty, and the 
anesthesia services provided on June 16, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on September 05, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you do not agree 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 $45 
copayment for each in-network Medicare-covered visit with a specialist. 
 
You have been asked to pay a $45 copayment for an office visit. This item/service falls within the each in-
network Medicare-covered visit 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. Therefore, we decided that the Plan does not have to waive the 
copayment for an office visit provided on September 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the audiology testing and physical therapy 
services on December 19, 2022. 
 
You asked the Plan to waive the copayments for the audiology testing and physical therapy services. You say 
that you don't feel liable. 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 $100 
copayment for diagnostic procedures and tests at outpatient hospital. You must pay a $35 copayment for 
Medicare-covered therapy visit. For both services it's $100 + $35 = $135. Therefore, results in the total cost 
sharing amount of $135. 
 
You have been asked to pay $100 copayment for the audiology testing and a $35 copayment for physical 
therapy services. This item/service falls within the outpatient diagnostic tests and therapeutic services and 
supplies and outpatient rehabilitation 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 copayments 
for the audiology testing and physical therapy services on December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services, first 20 minutes 
(99490) and chronic care management services, each additional 20 minutes (99439) provided on August 31, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chronic care management services. You say that please review and process 
the claim for payment. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered.  
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 the chronic care management services, first 20 
minutes (99490) and chronic care management services, each additional 20 minutes (99439) provided on 
August 31, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies for use with an implanted ventricular assist 
device provided on August 1, 2023, to August 31, 2023. 
 
You asked the Plan to pay for the supplies. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. The documentation 
submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of 
delivery. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the supplies for use with an implanted 
ventricular assist device provided on August 1, 2023, to August 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient surgery provided on June 
26, 2023. 
 
You asked the Plan to waive the coinsurance for the outpatient surgery. You say that you were told by the plan 
that the provider is in-network. 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 40% 
coinsurance for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
You have been asked to pay 40% coinsurance for the outpatient surgery. This item/service falls within the 
outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 $3,950.04 ($9,875.08 allowed amount x 20% = $3,950.04). Therefore, we decided that the 
Plan does not have to waive the coinsurance for the outpatient surgery provided on June 26, 2023.