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

 
We decided that the Plan does not have to pay for physician services provided to the enrollee from January 13, 
2020 to January 22, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care and you were not an 
eligible provider. 
 
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 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 physician services provided to the enrollee from January 13, 
2020 to January 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from 
January 16, 2020 to May 7, 2020. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you only ever paid a $5 
copayment for the injections and disagree with the additional charges. The Plan denied your request. The Plan 
says the claims were processed correctly and you are being charged the correct amount. 
 
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 Medicare Part B prescription drugs.  
 
You received Medicare Part B drugs provided on January 16, 2020. The total allowed amount is $152.34 and 
20% of that is $30.46. 
 
You received Medicare Part B drugs provided on February 13, 2020. The total allowed amount is $152.34 and 
20% of that is $30.46. 
 
You received Medicare Part B drugs provided on March 12, 2020. The total allowed amount is $152.34 and 
20% of that is $30.46. 
 
You received Medicare Part B drugs provided on April 9, 2020. The total allowed amount is $152.41 and 20% 
of that is $30.48. 
 
You received Medicare Part B drugs provided on May 7, 2020. The total allowed amount is $152.41 and 20% 
of that is $30.48. 
 
The total amount you owe is: $152.34. 
 
You have been asked to pay the total coinsurance amount of $152.34 for Medicare Part B drugs. Medicare Part 
B drugs 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 coinsurance for Medicare Part B drugs provided from January 16, 2020 to May 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360? molecular pathology genomic profiling 
provided to the enrollee on April 16, 2020. 
 
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The 
Plan says Medicare requires use of CPT 81479 to report a Guardant360? molecular pathology genomic 
profiling for NSCLC. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant360? molecular pathology genomic profiling provided to the enrollee on April 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiovascular PET scan (78492) 
performed on April 8, 2020. 
 
You asked the Plan to waive the copayment for a cardiovascular PET scan. You say that you were told there 
would be no copayments when you signed up for the Plan. 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 $95 
copayment for all diagnostic and nuclear medicine radiological services excluding mammography and 
ultrasounds.  
 
You have been asked to pay a $95 copayment for a cardiovascular PET scan. A cardiovascular PET scan falls 
within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a cardiovascular PET scan (78492) performed on April 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for lab services provided on April 30, 2020. 
 
You asked the Plan to waive the deductible for lab services. You say that you disagree with how high the 
charges are. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible for lab services. 
 
You received lab services on April 30, 2020. The record shows that you had paid $0 toward the $250 
deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of 
$69.47.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $250 deductible for lab services. This cost sharing is a contractual 
obligation that had not been met at the time lab services were received on April 30, 2020. Therefore, we 
decided that the Plan does not have to waive the deductible for lab services provided on April 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided during total 
abdominal hysterectomy provided on November 19, 2019. 
 
You asked the Plan to pay for the assistant surgeon services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services 
provided during total abdominal hysterectomy provided on November 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 24, 
2020 to January 25, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient admission was appropriate. 
The Plan denied your request. The Plan says the enrollee could have been treated in observation. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the emergency room on January 24, 2020 for the evaluation 
of cough and increased shortness of breath. She was evaluated and admitted with breathing symptoms felt to be 
related to chronic obstructive pulmonary disease (COPD). Following treatments in the emergency room she 
had no further breathing issues and had normal rate of breathing and amount of oxygen in her blood. She also 
reported on admission that she had not had a bowel movement in a week. She received MiraLAX and Senna 
and subsequently had bowel movements. She stated that her constipation was her biggest complaint and after 
the bowel movements she did not want any further evaluation/testing done and left against medical advice on 
January 25, 2020. The review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from January 24, 2020 to January 25, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reiki services rendered on January 1, 2019. 
 
You asked the Plan to pay for these services. You say that you would like reimbursement under the wellness 
benefit. The Plan denied your request. The Plan says the services are not covered. 
 
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 covers up to $150 for 
specific services under the Wellness Allowance. 
 
The Plan's rules for coverage of wellness benefits have not been met because reiki is not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for the reiki services rendered on January 1, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on April 22, 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 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee from January 6, 
2020 to January 10, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization and the provider is not eligible to provide 
this type of 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 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 physician services provided to the enrollee from 
January 6, 2020 to January 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $100 copayment charged for ambulance transport 
provided on April 1, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe you should have to pay this 
copayment. The Plan denied your request. The Plan says this copayment was charged based on the Plan 
contract agreement. 
 
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 ambulance transport.  
 
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 $100 copayment charged for ambulance transport provided on April 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 12, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the rules by not going 
to the emergency room because of COVID-19. The Plan denied your request. The Plan says these services are 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 12, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 12, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on April 7, 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 Plan must follow Medicare rules. The rules say that claims must be 
billed with the most precise diagnosis code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with a manifestation code as 
the primary diagnosis, and this is inappropriate billing per Medicare rules. Therefore, we decided that the Plan 
does not have to pay for the chest x-ray rendered on April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 5, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified dental service (D0999) provided on May 27, 
2020. 
 
You asked the Plan to pay for an unspecified dental service. You say that the enrollee had an exam and 
cleaning performed so this should be covered. The Plan denied your request. The Plan says this is not covered. 
 
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 
among those covered under this benefit. The submitted documentation does not show what service this code 
was used to report, therefore it cannot be verified whether it is among the Plan?s covered services. Therefore, 
we decided that the Plan does not have to pay for an unspecified dental service (D0999) provided on May 27, 
2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that custodial care is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the care is not complex enough and does not show it would cause 
excessive physical hardship for the patient to receive needed care in a SNF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require 
intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as 
physical and occupational therapy but the documentation does not support that your functional status requires 
or can fully tolerate an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer 
found that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary impression for palatal prosthesis (42280), 
impression/custom preparation' mandibular resection prosthesis (21081) and Impression and custom 
preparation; oral surgical splint (21085). 
 
You asked the Plan to pre-approve the services. You say that you would like reconsideration because you need 
this item to prevent infection from spreading. The Plan denied your request. The Plan says this service is not 
medically necessary. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there was no indication of any treatment planned for the maxillary palatal region. Therefore, the 
need for a palatal prosthesis has not been documented.  Treatment in the mandibular right posterior region 
could be performed via flap elevation and tissue removal.  The criteria for coverage for a mandibular resection 
prosthesis have not been documented. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve maxillary impression for palatal prosthesis (42280), impression/custom preparation' 
mandibular resection prosthesis (21081) and Impression and custom preparation; oral surgical splint (21085).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (CPT 85060) provided to the enrollee on 
February 13, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is denied as a duplicate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, a claim for these exact 
services was already paid on 3/31/20. Based on this information, we decided that Medicare rules for coverage 
of the services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(CPT 85060) provided to the enrollee on February 13, 2020.