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

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
chest you had on October 7, 2020. 
 
You asked the Plan to waive the copayment for the CT scan of the chest. You say that you do not feel as 
though you should have to pay this copayment because you had another CT scan six days prior to this one.  
You stated that you thought you were going to have a different test, not another CT scan. The Plan denied your 
request. The Plan says you were charged this copayment 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 diagnostic CT scans at a freestanding provider.  
 
You have been asked to pay a $50 copayment for the CT scan of the chest. This copayment applies regardless 
of the reason for the test. 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 computed tomography 
(CT) scan of the chest you had on October 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cardiac catheterization procedures 
(93460) provided October 8, 2019. 
 
You asked the Plan to waive the copayment for the cardiac catheterization procedures. You say that you 
believe this claim is beyond the period of contestability for them to file a claim against you and you do not 
believe the plain has paid enough of the co-payment based on the amount of coverage you have. The Plan 
denied your request. The Plan says the claim was processed and the correct coinsurance was applied per the 
Evidence of Coverage. 
 
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% of 
the total cost for each Medicare covered service provided in an outpatient hospital or an ambulatory surgical 
center, including but not limited to hospital or facility charges, observation room/stay charges, physician 
charges and surgical charges.  
 
You have been asked to pay $500.49 for the cardiac catheterization procedures. The plan paid 80% of the 
allowed amount of $2502.47 totaling $2001.98. The cardiac catheterization procedure 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 copayment for the cardiac catheterization 
procedures (93460) provided October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 20, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health services provided on December 9, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that you were not aware of a change in scope with 
your health plan. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.  The 
Plan says that you were advised of your new Plan's coverage rules prior to this service. 
 
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 behavioral health services provided on 
December 9, 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 hereditary comprehensive cardiovascular risk panel 
provided on August 1, 2020. 
 
You asked the Plan to pay for the comprehensive cardiovascular risk panel. You say that this was medically 
necessary testing. The Plan denied your request. The Plan says this testing is not medically necessary and was 
not billed with the correct Place of Service code. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. Medicare only covers certain tests for screening of cardiovascular risk. 
 
The genetic testing requested in this case was provided for screening purposes. No records were submitted to 
support that the results of this testing would affect management of the enrollee's condition. Therefore, we 
decided that the Plan does not have to pay for the hereditary comprehensive cardiovascular risk panel provided 
on August 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered.

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 testing is not covered.

The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered.

We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) received November 23, 2020. 
 
You asked the Plan to pay for the eye refraction. You say that the requested service should be covered. The 
Plan denied your request. The Plan says the eye refraction is only covered when performed as part of a routine 
exam and the provider confirmed that the refraction was performed as part of a medical exam. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. The provider has stated that the requested service was performed as 
part of a medical exam. The Plan only covers the requested service when performed as part of a routine eye 
exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) received 
November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on August 27, 
2020, September 1, 2020 and September 30, 2020. 
 
You asked the Plan to waive the copayment for the office visits. You say that you were misinformed and the 
$30 should be waived. The Plan denied your request. The Plan says the copayments applied 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 $10 
copayment for each specialist visit for Medicare-covered benefits. 
 
You have been asked to pay a $10 copayment for each office visit. The total amount you owe is $30 ($10/visit 
x 3 visits = $30). The office visits fall within the "Physician/Practitioner services, including doctor's office 
visits" 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 office visit provided on 
August 27, 2020, September 1, 2020 and September 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance services you 
received on August 19, 2020. 
 
You asked the Plan to waive the copayment for the emergency ambulance services. You did not provide an 
argument in your appeal request. The Plan denied your request. The Plan says you were charged this 
copayment 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 emergency ambulance services.  
 
You have been asked to pay a $200 copayment for the emergency ambulance services. 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 emergency ambulance services you received on August 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient physical therapy (PT) services 
provided September 1, 2020 to November 5, 2020. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were under the impression 
that the physical therapy was being tied into your hip surgery that was performed on 8/15/2020. Other services 
that have been rendered after the surgery did not have a copay. The Plan denied your request. The Plan says the 
correct copayment was applied per the Evidence of Coverage. 
 
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 
copayment for each Medicare covered therapy visit for Outpatient rehabilitation services.  
 
You have been asked to pay $380.95 for the PT services. The PT services falls within the 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 copayment for outpatient 
physical therapy (PT) services provided September 1, 2020 to November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit.

You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says that the Plan requires the utilization of in-network providers unless the plan pre-approves out-of-network services in non-emergent situations. The provider did not make attempts to verify the member's correct insurance, eligibility, or authorization requirements prior to rendering non-emergent 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 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 a domiciliary or rest home visit.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide services provided from August 31, 
2020, to September 4, 2020. 
 
You asked the Plan to pay for the home health aide. You say that the services were necessary. The Plan denied 
your request. The Plan says the provider in this case is not Medicare certified. The Plan also says that as a 
result, payment cannot be made. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health aide have not been met. Therefore, we decided that the Plan does not have to pay 
for the home health aide services provided from August 31, 2020, to September 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for basic radiology services provided by a 
participating provider on June 22, 2020. 
 
You asked the Plan to waive the copayment for basic radiology services. You say that you would like the 
money you overpaid back. The Plan denied your request. The Plan says the correct copayment 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 $5 
copayment for outpatient diagnostic tests/basic radiological services/PCP's office.  
 
You have been asked to pay a $5 copayment for basic radiology services. Basic radiology services fall within 
the outpatient diagnostic tests/basic radiological services/PCP's office 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 basic radiology services provided by a participating provider on June 
22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-
rays (D0274) provided on November 23, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation and bitewing x-rays. You say that you are not 
able to pay for these services. The Plan denied your request. The Plan says these services exceed the maximum 
count allowed per period. 
 
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, comprehensive oral evaluation 
(D0150) and is limited to one procedure every three plan years, and bitewing x-rays (codes D0270, D0272, 
D0273, D0274, or D0277) are limited to one procedure per plan year. The record shows that you received a 
comprehensive oral evaluation (D0150) on April 23, 2019, and you received bitewing x-rays (D0274) on May 
18, 2020 and your comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) benefits have been 
exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150) and bitewing x-rays (D0274) provided on November 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for MRI of the spine (CPT 72157) provided to the enrollee on 
July 30, 2020. 
 
You asked the Plan to pay for the MRI. You say that this should be paid for. The Plan denied your request. The 
Plan says this code was only performed once. 
 
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 72157 is "Magnetic resonance (eg, proton) imaging, 
spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences." 
 
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 pay for the MRI. Our reviewer says that the services 
at issue in this case were not supported by the medical records. Our physician reviewer found only one thoracic 
MRi was needed on the day of service. There is no medical justification in the records for 2 thoracic MRI 
exams. The records indicate one was already paid on that day. A second billing code is not justified and should 
not be paid. The enrollee has a thoracic lesion and only one recent MRI is needed. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pay for MRI of the spine (CPT 72157) provided to the enrollee on July 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on November 9, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you do not understand why 
you are being charged this amount when you have not had this copayment in the past. The Plan denied your 
request. The Plan says the correct copayment 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 $45 
copayment for physician/practitioner services/in-network/specialist.  
 
You have been asked to pay a $45 copayment for specialist services. The correct copayment has been applied 
to the services that were provided. Specialist services fall within the physician/practitioner services/in-
network/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 specialist services 
provided by a participating provider on November 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 31, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that you 
must receive your care from a network provider. In most cases, care you receive from an out-of-network 
provider will not be covered. If you need medical care that Medicare requires our Plan to cover and the 
providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, 
or your PCP, must obtain authorization from the Plan prior to seeking care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on July 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on December 2, 2020 by an out of network (OON) provider.

You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider or facility.

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 skilled nursing services provided on December 2, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prescription eye wear.

You asked the Plan to pay for prescription eye wear. You say that you would like the Plan to pay for the items as they have been covered before. The Plan denied your request. The Plan says it is not a covered benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when the Plan's supplemental vision benefits vendor is utilized.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of prescription eye wear have not been met. Specifically, the items were not purchased through the Plan's supplemental vision benefits vendor. Therefore, we decided that the Plan does not have to pay for prescription eye wear.