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

 
We decided that the Plan does not have to waive the copayment for the telehealth visit you had on March 25, 
2020 with an anesthesiologist. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that this amount should be waived 
because the HHS OIG stated that providers are supposed to waive cost sharing for telehealth services during 
the COVID-19 pandemic. The Plan denied your request. The Plan says you were charged this amount 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 $50 
copayment for services obtained from a specialist, including telehealth services.  
 
You have been asked to pay a $50 copayment for the telehealth visit. As noted above, the OIG issued a 
memorandum explicitly stating that providers are not required to reduce or waive any cost sharing obligations 
for telehealth services during the COVID-19 pandemic.  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 telehealth visit you had on March 25, 2020 with an anesthesiologist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on December 24, 2019. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on December 
24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 14, 2020 by an 
out-of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services were not authorized. The Plan states the member's primary care 
physician did not refer for services and the services were not urgent or emergent. 
 
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 has network providers 
available who can provide 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 medical services provided on February 14, 
2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) 
rendered by the out of network (OON) provider on March 12, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care, per day (99308) rendered by the out of network (OON) 
provider on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on March 11, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you have to get these injections 
every 3 months. You say that you cannot afford this coinsurance. The Plan denied your request. The Plan says 
the correct coinsurance has been applied. 
 
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 Medicare Part B prescription drugs/network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $1,780.22. The total amount you are being asked to pay is $356.04 ($1,780.22 x 20% = $256.04). An 
injection falls within the Medicare Part B prescription drugs/network 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 an injection provided by a participating provider on March 11, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on  
April 27, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $35 
copayment per visit to a specialist.  
 
You have been asked to pay a $35 copayment for the specialist office visit provided. 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 office visit (99213) provided on April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99334) rendered by the 
out of network (OON) provider on July 10, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit (99334) rendered by the out of network (OON) provider on 
July 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the full hereditary cancer panel provided on January 17, 
2020. 
 
You asked the Plan to pre-approve the cancer risk panel. You say that this testing was necessary to find the 
enrollee's cancer risk. The Plan denied your request. The Plan says this panel was not billed correctly. 
 
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 the cancer risk panel. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a 61-year-old woman with a personal history of cancer. A note states that the 
enrollee had breast cancer that started on the left side. There are no clinical records in the case file supporting 
that a Full Hereditary Cancer panel (32 genes) was medically reasonable and necessary  for the enrollee in this case. The documentation provided is insufficient to support an established relationship between the ordering provider and the enrollee or that the results were medically necessary to guide treatment. 
 
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 cancer risk panel have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the full hereditary cancer panel provided on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient occupational therapy provided 
by a participating provider on February 11, 2020 to May 23, 2020. 
 
You asked the Plan to waive the copayment for outpatient occupational therapy. You say that these services 
should have been included with the inpatient stay. The Plan denied your request. The Plan says the correct 
copayments have been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $40 copayment for outpatient rehabilitation services/occupational therapy.  
 
The enrollee has been asked to pay a $40 copayment each for outpatient occupational therapy. The total 
amount you are being asked to pay is $1,280 ($40 x 32 visits = $1,280). Outpatient occupational therapy falls 
within the outpatient rehabilitation services/occupational therapy benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for outpatient occupational therapy provided by a participating provider on 
February 11, 2020 to May 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient radiology services, 
radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic 
(SPECT) (78803) provided June 1, 2020. 
 
You asked the Plan to waive the copayment for the outpatient radiology services. You say that you were told 
by the plan that you would have a $200 copay for services and you was on the phone with that representative 
for a while. The Plan denied your request. The Plan says the coinsurance that was applied to the claim was not 
supported by the plan benefits and was overturned by the plan. The $275 copayment was applied correctly per 
the plan benefits. 
 
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 $275 
copayment for each advanced imaging service.  
 
You have been asked to pay $275 for the outpatient radiology services. The outpatient radiology 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 waive the copayment for 
the outpatient radiology services, radiopharmaceutical localization of tumor or distribution of 
radiopharmaceutical agent(s); tomographic (SPECT) (78803) provided June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 10, 2020 to April 
13, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that the enrollee is a resident at a nursing facility and 
has an authorization on file for all care at the facility. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because this provider is out-of-network with the Plan and authorization 
was not obtained. 
 
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 has network providers 
available who can provide 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 medical services provided on February 10, 
2020 to April 13, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on January 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 has network providers 
available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on January 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay on March 22 to 
March 25, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were transferred 
from another facility and should not be charged for a new admission. The Plan denied your request. The Plan 
says the correct copayment was applied. 
 
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 $300 
copayment for each day of days 1-6 of Medicare-covered hospital care.  
 
You have been asked to pay $900, or a $300 copayment for each day for 3 days, for an inpatient hospital stay. 
The Plan contract says that a transfer to a separate facility type is considered a new admission. An inpatient 
hospital stay 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 an inpatient hospital stay on March 22 to March 25, 2020.  
 
Your complaint about receiving erroneous or misleading information from representatives of the hospital is not 
a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the personal training sessions purchased 
on December 4, 2019. 
 
You asked the Plan to provide reimbursement for the personal training sessions. You say that you feel that you 
should be reimbursed since the reimbursement form clearly includes personal training as a covered benefit. The 
Plan denied your request. The Plan says your contract does not offer the benefit which you are requesting. Your 
plan only offers a $75 gift card for those who participate in certain wellness activities identified by the plan. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's Wellness benefit 
provides a $75 gift card for completing certain preventive wellness services such as participation in the 
SilverSneakers program.  
 
The Plan's rules for coverage of gym benefits have not been met because the gift card is not available for 
reimbursement of the cost of personal training services. The information listed on the reimbursement form you 
provided does not correspond to the wellness benefit offered by your particular plan design. Therefore, we 
decided that the Plan does not have to provide reimbursement for the personal training sessions purchased on 
December 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on March 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 has network providers 
available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on April 17, 2020. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 panel rendered on April 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on 
March 3, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the Plan referred to 
this provider. The Plan denied your request. The Plan says the treating provider is not a part of the Plan's 
network. The Plan also says that you nor the office contacted the Plan to verify eligibility or a benefit 
breakdown. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation and prophylaxis provided on March 3, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a stay at an inpatient rehabilitation facility 
on April 23 to May 5, 2020. 
 
You asked the Plan to waive the copayment for a stay at an inpatient rehabilitation facility. You say that this 
service should be covered 100% because it was related to COVID-19. The Plan denied your request. The Plan 
says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $150 copayment per day for days 1-5 per admission for each medically necessary inpatient stay.  
 
In this case, the record documents that the enrollee was tested for COVID-19 prior to admission to an inpatient 
rehabilitation facility. The test was negative. Therefore, the enrollee's stay at an inpatient rehabilitation facility 
was not related to COVID-19. The enrollee has been asked to pay a $150 copayment per day for days 1-5 for a 
stay at an inpatient rehabilitation facility. A stay at an inpatient rehabilitation facility falls within the "Inpatient 
hospital care" benefit category. This means that the enrollee has been asked to pay the correct amount based on 
the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a stay at an 
inpatient rehabilitation facility on April 23 to May 5, 2020.